Illinois General Assembly - Full Text of HB4408
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Full Text of HB4408  102nd General Assembly


Rep. Deb Conroy

Filed: 2/8/2022





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2    AMENDMENT NO. ______. Amend House Bill 4408 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.23 as follows:
6    (215 ILCS 5/356z.23)
7    Sec. 356z.23. Coverage for opioid antagonists.
8    (a) An individual or group policy of accident and health
9insurance amended, delivered, issued, or renewed in this State
10after the effective date of this amendatory Act of the 99th
11General Assembly that provides coverage for prescription drugs
12must provide coverage for at least one opioid antagonist,
13including the medication product, administration devices, and
14any pharmacy administration fees related to the dispensing of
15the opioid antagonist. This coverage must include refills for
16expired or utilized opioid antagonists.



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1    (a-5) Notwithstanding subsection (a), no individual or
2group policy of accident and health insurance amended,
3delivered, issued, or renewed after January 1, 2024 that
4provides coverage for naloxone hydrochloride shall impose a
5copayment on the coverage provided, except that this
6subsection does not apply to coverage of naloxone
7hydrochloride to the extent such coverage would disqualify a
8high-deductible health plan from eligibility for a health
9savings account under Section 223 of the Internal Revenue
11    (b) As used in this Section, "opioid antagonist" means a
12drug that binds to opioid receptors and blocks or inhibits the
13effect of opioids acting on those receptors, including, but
14not limited to, naloxone hydrochloride or any other similarly
15acting drug approved by the U.S. Food and Drug Administration.
16(Source: P.A. 99-480, eff. 9-9-15.)
17    Section 10. The Illinois Public Aid Code is amended by
18changing Section 5-5 as follows:
19    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
20    Sec. 5-5. Medical services. The Illinois Department, by
21rule, shall determine the quantity and quality of and the rate
22of reimbursement for the medical assistance for which payment
23will be authorized, and the medical services to be provided,
24which may include all or part of the following: (1) inpatient



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



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



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1    Notwithstanding any other provision of this Code,
2reproductive health care that is otherwise legal in Illinois
3shall be covered under the medical assistance program for
4persons who are otherwise eligible for medical assistance
5under this Article.
6    Notwithstanding any other provision of this Section, all
7tobacco cessation medications approved by the United States
8Food and Drug Administration and all individual and group
9tobacco cessation counseling services and telephone-based
10counseling services and tobacco cessation medications provided
11through the Illinois Tobacco Quitline shall be covered under
12the medical assistance program for persons who are otherwise
13eligible for assistance under this Article. The Department
14shall comply with all federal requirements necessary to obtain
15federal financial participation, as specified in 42 CFR
16433.15(b)(7), for telephone-based counseling services provided
17through the Illinois Tobacco Quitline, including, but not
18limited to: (i) entering into a memorandum of understanding or
19interagency agreement with the Department of Public Health, as
20administrator of the Illinois Tobacco Quitline; and (ii)
21developing a cost allocation plan for Medicaid-allowable
22Illinois Tobacco Quitline services in accordance with 45 CFR
2395.507. The Department shall submit the memorandum of
24understanding or interagency agreement, the cost allocation
25plan, and all other necessary documentation to the Centers for
26Medicare and Medicaid Services for review and approval.



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



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



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



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1and set requirements for follow-up referral care based on the
2requirements established in the Dental Office Reference Manual
3published by the Department that establishes the requirements
4for dentists participating in the All Kids Dental School
5Program. Every effort shall be made by the Department when
6developing the program requirements to consider the different
7geographic differences of both urban and rural areas of the
8State for initial treatment and necessary follow-up care. No
9provider shall be charged a fee by any unit of local government
10to participate in the school-based dental program administered
11by the Department. Nothing in this paragraph shall be
12construed to limit or preempt a home rule unit's or school
13district's authority to establish, change, or administer a
14school-based dental program in addition to, or independent of,
15the school-based dental program administered by the
17    The Illinois Department, by rule, may distinguish and
18classify the medical services to be provided only in
19accordance with the classes of persons designated in Section
21    The Department of Healthcare and Family Services must
22provide coverage and reimbursement for amino acid-based
23elemental formulas, regardless of delivery method, for the
24diagnosis and treatment of (i) eosinophilic disorders and (ii)
25short bowel syndrome when the prescribing physician has issued
26a written order stating that the amino acid-based elemental



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



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



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1less than one rad per breast for 2 views of an average size
2breast. The term also includes digital mammography and
3includes breast tomosynthesis.
4    "Breast tomosynthesis" means a radiologic procedure that
5involves the acquisition of projection images over the
6stationary breast to produce cross-sectional digital
7three-dimensional images of the breast.
8    If, at any time, the Secretary of the United States
9Department of Health and Human Services, or its successor
10agency, promulgates rules or regulations to be published in
11the Federal Register or publishes a comment in the Federal
12Register or issues an opinion, guidance, or other action that
13would require the State, pursuant to any provision of the
14Patient Protection and Affordable Care Act (Public Law
15111-148), including, but not limited to, 42 U.S.C.
1618031(d)(3)(B) or any successor provision, to defray the cost
17of any coverage for breast tomosynthesis outlined in this
18paragraph, then the requirement that an insurer cover breast
19tomosynthesis is inoperative other than any such coverage
20authorized under Section 1902 of the Social Security Act, 42
21U.S.C. 1396a, and the State shall not assume any obligation
22for the cost of coverage for breast tomosynthesis set forth in
23this paragraph.
24    On and after January 1, 2016, the Department shall ensure
25that all networks of care for adult clients of the Department
26include access to at least one breast imaging Center of



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1Imaging Excellence as certified by the American College of
3    On and after January 1, 2012, providers participating in a
4quality improvement program approved by the Department shall
5be reimbursed for screening and diagnostic mammography at the
6same rate as the Medicare program's rates, including the
7increased reimbursement for digital mammography.
8    The Department shall convene an expert panel including
9representatives of hospitals, free-standing mammography
10facilities, and doctors, including radiologists, to establish
11quality standards for mammography.
12    On and after January 1, 2017, providers participating in a
13breast cancer treatment quality improvement program approved
14by the Department shall be reimbursed for breast cancer
15treatment at a rate that is no lower than 95% of the Medicare
16program's rates for the data elements included in the breast
17cancer treatment quality program.
18    The Department shall convene an expert panel, including
19representatives of hospitals, free-standing breast cancer
20treatment centers, breast cancer quality organizations, and
21doctors, including breast surgeons, reconstructive breast
22surgeons, oncologists, and primary care providers to establish
23quality standards for breast cancer treatment.
24    Subject to federal approval, the Department shall
25establish a rate methodology for mammography at federally
26qualified health centers and other encounter-rate clinics.



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1These clinics or centers may also collaborate with other
2hospital-based mammography facilities. By January 1, 2016, the
3Department shall report to the General Assembly on the status
4of the provision set forth in this paragraph.
5    The Department shall establish a methodology to remind
6individuals who are age-appropriate for screening mammography,
7but who have not received a mammogram within the previous 18
8months, of the importance and benefit of screening
9mammography. The Department shall work with experts in breast
10cancer outreach and patient navigation to optimize these
11reminders and shall establish a methodology for evaluating
12their effectiveness and modifying the methodology based on the
14    The Department shall establish a performance goal for
15primary care providers with respect to their female patients
16over age 40 receiving an annual mammogram. This performance
17goal shall be used to provide additional reimbursement in the
18form of a quality performance bonus to primary care providers
19who meet that goal.
20    The Department shall devise a means of case-managing or
21patient navigation for beneficiaries diagnosed with breast
22cancer. This program shall initially operate as a pilot
23program in areas of the State with the highest incidence of
24mortality related to breast cancer. At least one pilot program
25site shall be in the metropolitan Chicago area and at least one
26site shall be outside the metropolitan Chicago area. On or



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1after July 1, 2016, the pilot program shall be expanded to
2include one site in western Illinois, one site in southern
3Illinois, one site in central Illinois, and 4 sites within
4metropolitan Chicago. An evaluation of the pilot program shall
5be carried out measuring health outcomes and cost of care for
6those served by the pilot program compared to similarly
7situated patients who are not served by the pilot program.
8    The Department shall require all networks of care to
9develop a means either internally or by contract with experts
10in navigation and community outreach to navigate cancer
11patients to comprehensive care in a timely fashion. The
12Department shall require all networks of care to include
13access for patients diagnosed with cancer to at least one
14academic commission on cancer-accredited cancer program as an
15in-network covered benefit.
16    On or after July 1, 2022, individuals who are otherwise
17eligible for medical assistance under this Article shall
18receive coverage for perinatal depression screenings for the
1912-month period beginning on the last day of their pregnancy.
20Medical assistance coverage under this paragraph shall be
21conditioned on the use of a screening instrument approved by
22the Department.
23    Any medical or health care provider shall immediately
24recommend, to any pregnant individual who is being provided
25prenatal services and is suspected of having a substance use
26disorder as defined in the Substance Use Disorder Act,



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



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2    The Illinois Department shall establish such regulations
3governing the dispensing of health services under this Article
4as it shall deem appropriate. The Department should seek the
5advice of formal professional advisory committees appointed by
6the Director of the Illinois Department for the purpose of
7providing regular advice on policy and administrative matters,
8information dissemination and educational activities for
9medical and health care providers, and consistency in
10procedures to the Illinois Department.
11    The Illinois Department may develop and contract with
12Partnerships of medical providers to arrange medical services
13for persons eligible under Section 5-2 of this Code.
14Implementation of this Section may be by demonstration
15projects in certain geographic areas. The Partnership shall be
16represented by a sponsor organization. The Department, by
17rule, shall develop qualifications for sponsors of
18Partnerships. Nothing in this Section shall be construed to
19require that the sponsor organization be a medical
21    The sponsor must negotiate formal written contracts with
22medical providers for physician services, inpatient and
23outpatient hospital care, home health services, treatment for
24alcoholism and substance abuse, and other services determined
25necessary by the Illinois Department by rule for delivery by
26Partnerships. Physician services must include prenatal and



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



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



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



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1    Notwithstanding any other law to the contrary, the
2Illinois Department shall, within 365 days after July 22, 2013
3(the effective date of Public Act 98-104), establish
4procedures to permit skilled care facilities licensed under
5the Nursing Home Care Act to submit monthly billing claims for
6reimbursement purposes. Following development of these
7procedures, the Department shall, by July 1, 2016, test the
8viability of the new system and implement any necessary
9operational or structural changes to its information
10technology platforms in order to allow for the direct
11acceptance and payment of nursing home claims.
12    Notwithstanding any other law to the contrary, the
13Illinois Department shall, within 365 days after August 15,
142014 (the effective date of Public Act 98-963), establish
15procedures to permit ID/DD facilities licensed under the ID/DD
16Community Care Act and MC/DD facilities licensed under the
17MC/DD Act to submit monthly billing claims for reimbursement
18purposes. Following development of these procedures, the
19Department shall have an additional 365 days to test the
20viability of the new system and to ensure that any necessary
21operational or structural changes to its information
22technology platforms are implemented.
23    The Illinois Department shall require all dispensers of
24medical services, other than an individual practitioner or
25group of practitioners, desiring to participate in the Medical
26Assistance program established under this Article to disclose



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1all financial, beneficial, ownership, equity, surety or other
2interests in any and all firms, corporations, partnerships,
3associations, business enterprises, joint ventures, agencies,
4institutions or other legal entities providing any form of
5health care services in this State under this Article.
6    The Illinois Department may require that all dispensers of
7medical services desiring to participate in the medical
8assistance program established under this Article disclose,
9under such terms and conditions as the Illinois Department may
10by rule establish, all inquiries from clients and attorneys
11regarding medical bills paid by the Illinois Department, which
12inquiries could indicate potential existence of claims or
13liens for the Illinois Department.
14    Enrollment of a vendor shall be subject to a provisional
15period and shall be conditional for one year. During the
16period of conditional enrollment, the Department may terminate
17the vendor's eligibility to participate in, or may disenroll
18the vendor from, the medical assistance program without cause.
19Unless otherwise specified, such termination of eligibility or
20disenrollment is not subject to the Department's hearing
21process. However, a disenrolled vendor may reapply without
23    The Department has the discretion to limit the conditional
24enrollment period for vendors based upon category of risk of
25the vendor.
26    Prior to enrollment and during the conditional enrollment



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



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1medical goods or services were provided, with the following
3        (1) In the case of a provider whose enrollment is in
4    process by the Illinois Department, the 180-day period
5    shall not begin until the date on the written notice from
6    the Illinois Department that the provider enrollment is
7    complete.
8        (2) In the case of errors attributable to the Illinois
9    Department or any of its claims processing intermediaries
10    which result in an inability to receive, process, or
11    adjudicate a claim, the 180-day period shall not begin
12    until the provider has been notified of the error.
13        (3) In the case of a provider for whom the Illinois
14    Department initiates the monthly billing process.
15        (4) In the case of a provider operated by a unit of
16    local government with a population exceeding 3,000,000
17    when local government funds finance federal participation
18    for claims payments.
19    For claims for services rendered during a period for which
20a recipient received retroactive eligibility, claims must be
21filed within 180 days after the Department determines the
22applicant is eligible. For claims for which the Illinois
23Department is not the primary payer, claims must be submitted
24to the Illinois Department within 180 days after the final
25adjudication by the primary payer.
26    In the case of long term care facilities, within 120



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



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



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



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



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1Certification if the refurbished durable medical equipment:
2(i) is available; (ii) is less expensive, including shipping
3costs, than new durable medical equipment of the same type;
4(iii) is able to withstand at least 3 years of use; (iv) is
5cleaned, disinfected, sterilized, and safe in accordance with
6federal Food and Drug Administration regulations and guidance
7governing the reprocessing of medical devices in health care
8settings; and (v) equally meets the needs of the recipient or
9enrollee. The reutilization program shall confirm that the
10recipient or enrollee is not already in receipt of the same or
11similar equipment from another service provider, and that the
12refurbished durable medical equipment equally meets the needs
13of the recipient or enrollee. Nothing in this paragraph shall
14be construed to limit recipient or enrollee choice to obtain
15new durable medical equipment or place any additional prior
16authorization conditions on enrollees of managed care
18    The Department shall execute, relative to the nursing home
19prescreening project, written inter-agency agreements with the
20Department of Human Services and the Department on Aging, to
21effect the following: (i) intake procedures and common
22eligibility criteria for those persons who are receiving
23non-institutional services; and (ii) the establishment and
24development of non-institutional services in areas of the
25State where they are not currently available or are
26undeveloped; and (iii) notwithstanding any other provision of



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1law, subject to federal approval, on and after July 1, 2012, an
2increase in the determination of need (DON) scores from 29 to
337 for applicants for institutional and home and
4community-based long term care; if and only if federal
5approval is not granted, the Department may, in conjunction
6with other affected agencies, implement utilization controls
7or changes in benefit packages to effectuate a similar savings
8amount for this population; and (iv) no later than July 1,
92013, minimum level of care eligibility criteria for
10institutional and home and community-based long term care; and
11(v) no later than October 1, 2013, establish procedures to
12permit long term care providers access to eligibility scores
13for individuals with an admission date who are seeking or
14receiving services from the long term care provider. In order
15to select the minimum level of care eligibility criteria, the
16Governor shall establish a workgroup that includes affected
17agency representatives and stakeholders representing the
18institutional and home and community-based long term care
19interests. This Section shall not restrict the Department from
20implementing lower level of care eligibility criteria for
21community-based services in circumstances where federal
22approval has been granted.
23    The Illinois Department shall develop and operate, in
24cooperation with other State Departments and agencies and in
25compliance with applicable federal laws and regulations,
26appropriate and effective systems of health care evaluation



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1and programs for monitoring of utilization of health care
2services and facilities, as it affects persons eligible for
3medical assistance under this Code.
4    The Illinois Department shall report annually to the
5General Assembly, no later than the second Friday in April of
61979 and each year thereafter, in regard to:
7        (a) actual statistics and trends in utilization of
8    medical services by public aid recipients;
9        (b) actual statistics and trends in the provision of
10    the various medical services by medical vendors;
11        (c) current rate structures and proposed changes in
12    those rate structures for the various medical vendors; and
13        (d) efforts at utilization review and control by the
14    Illinois Department.
15    The period covered by each report shall be the 3 years
16ending on the June 30 prior to the report. The report shall
17include suggested legislation for consideration by the General
18Assembly. The requirement for reporting to the General
19Assembly shall be satisfied by filing copies of the report as
20required by Section 3.1 of the General Assembly Organization
21Act, and filing such additional copies with the State
22Government Report Distribution Center for the General Assembly
23as is required under paragraph (t) of Section 7 of the State
24Library Act.
25    Rulemaking authority to implement Public Act 95-1045, if
26any, is conditioned on the rules being adopted in accordance



10200HB4408ham001- 32 -LRB102 22908 KTG 35534 a

1with all provisions of the Illinois Administrative Procedure
2Act and all rules and procedures of the Joint Committee on
3Administrative Rules; any purported rule not so adopted, for
4whatever reason, is unauthorized.
5    On and after July 1, 2012, the Department shall reduce any
6rate of reimbursement for services or other payments or alter
7any methodologies authorized by this Code to reduce any rate
8of reimbursement for services or other payments in accordance
9with Section 5-5e.
10    Because kidney transplantation can be an appropriate,
11cost-effective alternative to renal dialysis when medically
12necessary and notwithstanding the provisions of Section 1-11
13of this Code, beginning October 1, 2014, the Department shall
14cover kidney transplantation for noncitizens with end-stage
15renal disease who are not eligible for comprehensive medical
16benefits, who meet the residency requirements of Section 5-3
17of this Code, and who would otherwise meet the financial
18requirements of the appropriate class of eligible persons
19under Section 5-2 of this Code. To qualify for coverage of
20kidney transplantation, such person must be receiving
21emergency renal dialysis services covered by the Department.
22Providers under this Section shall be prior approved and
23certified by the Department to perform kidney transplantation
24and the services under this Section shall be limited to
25services associated with kidney transplantation.
26    Notwithstanding any other provision of this Code to the



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



10200HB4408ham001- 34 -LRB102 22908 KTG 35534 a

1coverage and reimbursement for all drugs that are approved for
2marketing by the federal Food and Drug Administration and that
3are recommended by the federal Public Health Service or the
4United States Centers for Disease Control and Prevention for
5pre-exposure prophylaxis and related pre-exposure prophylaxis
6services, including, but not limited to, HIV and sexually
7transmitted infection screening, treatment for sexually
8transmitted infections, medical monitoring, assorted labs, and
9counseling to reduce the likelihood of HIV infection among
10individuals who are not infected with HIV but who are at high
11risk of HIV infection.
12    A federally qualified health center, as defined in Section
131905(l)(2)(B) of the federal Social Security Act, shall be
14reimbursed by the Department in accordance with the federally
15qualified health center's encounter rate for services provided
16to medical assistance recipients that are performed by a
17dental hygienist, as defined under the Illinois Dental
18Practice Act, working under the general supervision of a
19dentist and employed by a federally qualified health center.
20    Within 90 days after October 8, 2021 (the effective date
21of Public Act 102-665) this amendatory Act of the 102nd
22General Assembly, the Department shall seek federal approval
23of a State Plan amendment to expand coverage for family
24planning services that includes presumptive eligibility to
25individuals whose income is at or below 208% of the federal
26poverty level. Coverage under this Section shall be effective



10200HB4408ham001- 35 -LRB102 22908 KTG 35534 a

1beginning no later than December 1, 2022.
2    Subject to approval by the federal Centers for Medicare
3and Medicaid Services of a Title XIX State Plan amendment
4electing the Program of All-Inclusive Care for the Elderly
5(PACE) as a State Medicaid option, as provided for by Subtitle
6I (commencing with Section 4801) of Title IV of the Balanced
7Budget Act of 1997 (Public Law 105-33) and Part 460
8(commencing with Section 460.2) of Subchapter E of Title 42 of
9the Code of Federal Regulations, PACE program services shall
10become a covered benefit of the medical assistance program,
11subject to criteria established in accordance with all
12applicable laws.
13    Notwithstanding any other provision of this Code,
14community-based pediatric palliative care from a trained
15interdisciplinary team shall be covered under the medical
16assistance program as provided in Section 15 of the Pediatric
17Palliative Care Act.
18(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
19102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
2035, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
2155-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
22102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
231-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)".