Illinois General Assembly - Full Text of HB1384
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Full Text of HB1384  103rd General Assembly


Rep. Kelly M. Cassidy

Filed: 2/27/2023





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2    AMENDMENT NO. ______. Amend House Bill 1384 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Insurance Code is amended by
5adding Section 356z.61 as follows:
6    (215 ILCS 5/356z.61 new)
7    Sec. 356z.61. Coverage for reconstructive services.
8    (a) As used in this Section, "reconstructive services"
9means treatments performed on structures of the body damaged
10by trauma to restore physical appearance.
11    (b) A group or individual policy of accident and health
12insurance or a managed care plan that is amended, delivered,
13issued, or renewed on or after January 1, 2025 may not deny
14coverage for medically necessary reconstructive services that
15are intended to restore physical appearance.



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1    Section 10. The Health Maintenance Organization Act is
2amended by changing Section 5-3 as follows:
3    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
4    Sec. 5-3. Insurance Code provisions.
5    (a) Health Maintenance Organizations shall be subject to
6the provisions of Sections 133, 134, 136, 137, 139, 140,
7141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
8154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
9355.3, 355b, 355c, 356g.5-1, 356m, 356q, 356v, 356w, 356x,
10356y, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6,
11356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
12356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25,
13356z.26, 356z.29, 356z.30, 356z.30a, 356z.32, 356z.33,
14356z.35, 356z.36, 356z.40, 356z.41, 356z.46, 356z.47, 356z.48,
15356z.50, 356z.51, 356z.53 256z.53, 356z.54, 356z.56, 356z.57,
16356z.59, 356z.60, 356z.61, 364, 364.01, 364.3, 367.2, 367.2-5,
17367i, 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1,
18402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
19paragraph (c) of subsection (2) of Section 367, and Articles
20IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
21XXXIIB of the Illinois Insurance Code.
22    (b) For purposes of the Illinois Insurance Code, except
23for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
24Health Maintenance Organizations in the following categories
25are deemed to be "domestic companies":



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



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1    following information:
2            (A) certification by an independent actuary of the
3        adequacy of the reserves of the Health Maintenance
4        Organization sought to be acquired;
5            (B) pro forma financial statements reflecting the
6        combined balance sheets of the acquiring company and
7        the Health Maintenance Organization sought to be
8        acquired as of the end of the preceding year and as of
9        a date 90 days prior to the acquisition, as well as pro
10        forma financial statements reflecting projected
11        combined operation for a period of 2 years;
12            (C) a pro forma business plan detailing an
13        acquiring party's plans with respect to the operation
14        of the Health Maintenance Organization sought to be
15        acquired for a period of not less than 3 years; and
16            (D) such other information as the Director shall
17        require.
18    (d) The provisions of Article VIII 1/2 of the Illinois
19Insurance Code and this Section 5-3 shall apply to the sale by
20any health maintenance organization of greater than 10% of its
21enrollee population (including without limitation the health
22maintenance organization's right, title, and interest in and
23to its health care certificates).
24    (e) In considering any management contract or service
25agreement subject to Section 141.1 of the Illinois Insurance
26Code, the Director (i) shall, in addition to the criteria



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



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1    be calculated taking into account a pro rata share of the
2    Health Maintenance Organization's administrative and
3    marketing expenses, but shall not include any refund to be
4    made or additional premium to be paid pursuant to this
5    subsection (f)). The Health Maintenance Organization and
6    the group or enrollment unit may agree that the profitable
7    or unprofitable experience may be calculated taking into
8    account the refund period and the immediately preceding 2
9    plan years.
10    The Health Maintenance Organization shall include a
11statement in the evidence of coverage issued to each enrollee
12describing the possibility of a refund or additional premium,
13and upon request of any group or enrollment unit, provide to
14the group or enrollment unit a description of the method used
15to calculate (1) the Health Maintenance Organization's
16profitable experience with respect to the group or enrollment
17unit and the resulting refund to the group or enrollment unit
18or (2) the Health Maintenance Organization's unprofitable
19experience with respect to the group or enrollment unit and
20the resulting additional premium to be paid by the group or
21enrollment unit.
22    In no event shall the Illinois Health Maintenance
23Organization Guaranty Association be liable to pay any
24contractual obligation of an insolvent organization to pay any
25refund authorized under this Section.
26    (g) Rulemaking authority to implement Public Act 95-1045,



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1if any, is conditioned on the rules being adopted in
2accordance with all provisions of the Illinois Administrative
3Procedure Act and all rules and procedures of the Joint
4Committee on Administrative Rules; any purported rule not so
5adopted, for whatever reason, is unauthorized.
6(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
7101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
81-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
9eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
10102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
111-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
12eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
13102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
141-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
15eff. 1-1-23; 102-1117, eff. 1-13-23; revised 1-22-23.)
16    Section 15. The Illinois Public Aid Code is amended by
17changing Section 5-5 as follows:
18    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
19    Sec. 5-5. Medical services. The Illinois Department, by
20rule, shall determine the quantity and quality of and the rate
21of reimbursement for the medical assistance for which payment
22will be authorized, and the medical services to be provided,
23which may include all or part of the following: (1) inpatient
24hospital services; (2) outpatient hospital services; (3) other



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



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



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1reproductive health care that is otherwise legal in Illinois
2shall be covered under the medical assistance program for
3persons who are otherwise eligible for medical assistance
4under this Article.
5    Notwithstanding any other provision of this Section, all
6tobacco cessation medications approved by the United States
7Food and Drug Administration and all individual and group
8tobacco cessation counseling services and telephone-based
9counseling services and tobacco cessation medications provided
10through the Illinois Tobacco Quitline shall be covered under
11the medical assistance program for persons who are otherwise
12eligible for assistance under this Article. The Department
13shall comply with all federal requirements necessary to obtain
14federal financial participation, as specified in 42 CFR
15433.15(b)(7), for telephone-based counseling services provided
16through the Illinois Tobacco Quitline, including, but not
17limited to: (i) entering into a memorandum of understanding or
18interagency agreement with the Department of Public Health, as
19administrator of the Illinois Tobacco Quitline; and (ii)
20developing a cost allocation plan for Medicaid-allowable
21Illinois Tobacco Quitline services in accordance with 45 CFR
2295.507. The Department shall submit the memorandum of
23understanding or interagency agreement, the cost allocation
24plan, and all other necessary documentation to the Centers for
25Medicare and Medicaid Services for review and approval.
26Coverage under this paragraph shall be contingent upon federal



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



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



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



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



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



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



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1breast. The term also includes digital mammography and
2includes breast tomosynthesis.
3    "Breast tomosynthesis" means a radiologic procedure that
4involves the acquisition of projection images over the
5stationary breast to produce cross-sectional digital
6three-dimensional images of the breast.
7    If, at any time, the Secretary of the United States
8Department of Health and Human Services, or its successor
9agency, promulgates rules or regulations to be published in
10the Federal Register or publishes a comment in the Federal
11Register or issues an opinion, guidance, or other action that
12would require the State, pursuant to any provision of the
13Patient Protection and Affordable Care Act (Public Law
14111-148), including, but not limited to, 42 U.S.C.
1518031(d)(3)(B) or any successor provision, to defray the cost
16of any coverage for breast tomosynthesis outlined in this
17paragraph, then the requirement that an insurer cover breast
18tomosynthesis is inoperative other than any such coverage
19authorized under Section 1902 of the Social Security Act, 42
20U.S.C. 1396a, and the State shall not assume any obligation
21for the cost of coverage for breast tomosynthesis set forth in
22this paragraph.
23    On and after January 1, 2016, the Department shall ensure
24that all networks of care for adult clients of the Department
25include access to at least one breast imaging Center of
26Imaging Excellence as certified by the American College of



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2    On and after January 1, 2012, providers participating in a
3quality improvement program approved by the Department shall
4be reimbursed for screening and diagnostic mammography at the
5same rate as the Medicare program's rates, including the
6increased reimbursement for digital mammography and, after
7January 1, 2023 (the effective date of Public Act 102-1018)
8this amendatory Act of the 102nd General Assembly, breast
10    The Department shall convene an expert panel including
11representatives of hospitals, free-standing mammography
12facilities, and doctors, including radiologists, to establish
13quality standards for mammography.
14    On and after January 1, 2017, providers participating in a
15breast cancer treatment quality improvement program approved
16by the Department shall be reimbursed for breast cancer
17treatment at a rate that is no lower than 95% of the Medicare
18program's rates for the data elements included in the breast
19cancer treatment quality program.
20    The Department shall convene an expert panel, including
21representatives of hospitals, free-standing breast cancer
22treatment centers, breast cancer quality organizations, and
23doctors, including breast surgeons, reconstructive breast
24surgeons, oncologists, and primary care providers to establish
25quality standards for breast cancer treatment.
26    Subject to federal approval, the Department shall



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



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1site shall be in the metropolitan Chicago area and at least one
2site shall be outside the metropolitan Chicago area. On or
3after July 1, 2016, the pilot program shall be expanded to
4include one site in western Illinois, one site in southern
5Illinois, one site in central Illinois, and 4 sites within
6metropolitan Chicago. An evaluation of the pilot program shall
7be carried out measuring health outcomes and cost of care for
8those served by the pilot program compared to similarly
9situated patients who are not served by the pilot program.
10    The Department shall require all networks of care to
11develop a means either internally or by contract with experts
12in navigation and community outreach to navigate cancer
13patients to comprehensive care in a timely fashion. The
14Department shall require all networks of care to include
15access for patients diagnosed with cancer to at least one
16academic commission on cancer-accredited cancer program as an
17in-network covered benefit.
18    The Department shall provide coverage and reimbursement
19for a human papillomavirus (HPV) vaccine that is approved for
20marketing by the federal Food and Drug Administration for all
21persons between the ages of 9 and 45 and persons of the age of
2246 and above who have been diagnosed with cervical dysplasia
23with a high risk of recurrence or progression. The Department
24shall disallow any preauthorization requirements for the
25administration of the human papillomavirus (HPV) vaccine.
26    On or after July 1, 2022, individuals who are otherwise



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1eligible for medical assistance under this Article shall
2receive coverage for perinatal depression screenings for the
312-month period beginning on the last day of their pregnancy.
4Medical assistance coverage under this paragraph shall be
5conditioned on the use of a screening instrument approved by
6the Department.
7    Any medical or health care provider shall immediately
8recommend, to any pregnant individual who is being provided
9prenatal services and is suspected of having a substance use
10disorder as defined in the Substance Use Disorder Act,
11referral to a local substance use disorder treatment program
12licensed by the Department of Human Services or to a licensed
13hospital which provides substance abuse treatment services.
14The Department of Healthcare and Family Services shall assure
15coverage for the cost of treatment of the drug abuse or
16addiction for pregnant recipients in accordance with the
17Illinois Medicaid Program in conjunction with the Department
18of Human Services.
19    All medical providers providing medical assistance to
20pregnant individuals under this Code shall receive information
21from the Department on the availability of services under any
22program providing case management services for addicted
23individuals, including information on appropriate referrals
24for other social services that may be needed by addicted
25individuals in addition to treatment for addiction.
26    The Illinois Department, in cooperation with the



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1Departments of Human Services (as successor to the Department
2of Alcoholism and Substance Abuse) and Public Health, through
3a public awareness campaign, may provide information
4concerning treatment for alcoholism and drug abuse and
5addiction, prenatal health care, and other pertinent programs
6directed at reducing the number of drug-affected infants born
7to recipients of medical assistance.
8    Neither the Department of Healthcare and Family Services
9nor the Department of Human Services shall sanction the
10recipient solely on the basis of the recipient's substance
12    The Illinois Department shall establish such regulations
13governing the dispensing of health services under this Article
14as it shall deem appropriate. The Department should seek the
15advice of formal professional advisory committees appointed by
16the Director of the Illinois Department for the purpose of
17providing regular advice on policy and administrative matters,
18information dissemination and educational activities for
19medical and health care providers, and consistency in
20procedures to the Illinois Department.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration
25projects in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by



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1rule, shall develop qualifications for sponsors of
2Partnerships. Nothing in this Section shall be construed to
3require that the sponsor organization be a medical
5    The sponsor must negotiate formal written contracts with
6medical providers for physician services, inpatient and
7outpatient hospital care, home health services, treatment for
8alcoholism and substance abuse, and other services determined
9necessary by the Illinois Department by rule for delivery by
10Partnerships. Physician services must include prenatal and
11obstetrical care. The Illinois Department shall reimburse
12medical services delivered by Partnership providers to clients
13in target areas according to provisions of this Article and
14the Illinois Health Finance Reform Act, except that:
15        (1) Physicians participating in a Partnership and
16    providing certain services, which shall be determined by
17    the Illinois Department, to persons in areas covered by
18    the Partnership may receive an additional surcharge for
19    such services.
20        (2) The Department may elect to consider and negotiate
21    financial incentives to encourage the development of
22    Partnerships and the efficient delivery of medical care.
23        (3) Persons receiving medical services through
24    Partnerships may receive medical and case management
25    services above the level usually offered through the
26    medical assistance program.



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



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1provided by applicable State law, whichever period is longer,
2except that if an audit is initiated within the required
3retention period then the records must be retained until the
4audit is completed and every exception is resolved. The
5Illinois Department shall require health care providers to
6make available, when authorized by the patient, in writing,
7the medical records in a timely fashion to other health care
8providers who are treating or serving persons eligible for
9Medical Assistance under this Article. All dispensers of
10medical services shall be required to maintain and retain
11business and professional records sufficient to fully and
12accurately document the nature, scope, details and receipt of
13the health care provided to persons eligible for medical
14assistance under this Code, in accordance with regulations
15promulgated by the Illinois Department. The rules and
16regulations shall require that proof of the receipt of
17prescription drugs, dentures, prosthetic devices and
18eyeglasses by eligible persons under this Section accompany
19each claim for reimbursement submitted by the dispenser of
20such medical services. No such claims for reimbursement shall
21be approved for payment by the Illinois Department without
22such proof of receipt, unless the Illinois Department shall
23have put into effect and shall be operating a system of
24post-payment audit and review which shall, on a sampling
25basis, be deemed adequate by the Illinois Department to assure
26that such drugs, dentures, prosthetic devices and eyeglasses



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1for which payment is being made are actually being received by
2eligible recipients. Within 90 days after September 16, 1984
3(the effective date of Public Act 83-1439), the Illinois
4Department shall establish a current list of acquisition costs
5for all prosthetic devices and any other items recognized as
6medical equipment and supplies reimbursable under this Article
7and shall update such list on a quarterly basis, except that
8the acquisition costs of all prescription drugs shall be
9updated no less frequently than every 30 days as required by
10Section 5-5.12.
11    Notwithstanding any other law to the contrary, the
12Illinois Department shall, within 365 days after July 22, 2013
13(the effective date of Public Act 98-104), establish
14procedures to permit skilled care facilities licensed under
15the Nursing Home Care Act to submit monthly billing claims for
16reimbursement purposes. Following development of these
17procedures, the Department shall, by July 1, 2016, test the
18viability of the new system and implement any necessary
19operational or structural changes to its information
20technology platforms in order to allow for the direct
21acceptance and payment of nursing home claims.
22    Notwithstanding any other law to the contrary, the
23Illinois Department shall, within 365 days after August 15,
242014 (the effective date of Public Act 98-963), establish
25procedures to permit ID/DD facilities licensed under the ID/DD
26Community Care Act and MC/DD facilities licensed under the



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1MC/DD Act to submit monthly billing claims for reimbursement
2purposes. Following development of these procedures, the
3Department shall have an additional 365 days to test the
4viability of the new system and to ensure that any necessary
5operational or structural changes to its information
6technology platforms are implemented.
7    The Illinois Department shall require all dispensers of
8medical services, other than an individual practitioner or
9group of practitioners, desiring to participate in the Medical
10Assistance program established under this Article to disclose
11all financial, beneficial, ownership, equity, surety or other
12interests in any and all firms, corporations, partnerships,
13associations, business enterprises, joint ventures, agencies,
14institutions or other legal entities providing any form of
15health care services in this State under this Article.
16    The Illinois Department may require that all dispensers of
17medical services desiring to participate in the medical
18assistance program established under this Article disclose,
19under such terms and conditions as the Illinois Department may
20by rule establish, all inquiries from clients and attorneys
21regarding medical bills paid by the Illinois Department, which
22inquiries could indicate potential existence of claims or
23liens for the Illinois Department.
24    Enrollment of a vendor shall be subject to a provisional
25period and shall be conditional for one year. During the
26period of conditional enrollment, the Department may terminate



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



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



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



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



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



10300HB1384ham001- 33 -LRB103 25389 BMS 57786 a

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



10300HB1384ham001- 34 -LRB103 25389 BMS 57786 a

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



10300HB1384ham001- 35 -LRB103 25389 BMS 57786 a

2    The Department shall execute, relative to the nursing home
3prescreening project, written inter-agency agreements with the
4Department of Human Services and the Department on Aging, to
5effect the following: (i) intake procedures and common
6eligibility criteria for those persons who are receiving
7non-institutional services; and (ii) the establishment and
8development of non-institutional services in areas of the
9State where they are not currently available or are
10undeveloped; and (iii) notwithstanding any other provision of
11law, subject to federal approval, on and after July 1, 2012, an
12increase in the determination of need (DON) scores from 29 to
1337 for applicants for institutional and home and
14community-based long term care; if and only if federal
15approval is not granted, the Department may, in conjunction
16with other affected agencies, implement utilization controls
17or changes in benefit packages to effectuate a similar savings
18amount for this population; and (iv) no later than July 1,
192013, minimum level of care eligibility criteria for
20institutional and home and community-based long term care; and
21(v) no later than October 1, 2013, establish procedures to
22permit long term care providers access to eligibility scores
23for individuals with an admission date who are seeking or
24receiving services from the long term care provider. In order
25to select the minimum level of care eligibility criteria, the
26Governor shall establish a workgroup that includes affected



10300HB1384ham001- 36 -LRB103 25389 BMS 57786 a

1agency representatives and stakeholders representing the
2institutional and home and community-based long term care
3interests. This Section shall not restrict the Department from
4implementing lower level of care eligibility criteria for
5community-based services in circumstances where federal
6approval has been granted.
7    The Illinois Department shall develop and operate, in
8cooperation with other State Departments and agencies and in
9compliance with applicable federal laws and regulations,
10appropriate and effective systems of health care evaluation
11and programs for monitoring of utilization of health care
12services and facilities, as it affects persons eligible for
13medical assistance under this Code.
14    The Illinois Department shall report annually to the
15General Assembly, no later than the second Friday in April of
161979 and each year thereafter, in regard to:
17        (a) actual statistics and trends in utilization of
18    medical services by public aid recipients;
19        (b) actual statistics and trends in the provision of
20    the various medical services by medical vendors;
21        (c) current rate structures and proposed changes in
22    those rate structures for the various medical vendors; and
23        (d) efforts at utilization review and control by the
24    Illinois Department.
25    The period covered by each report shall be the 3 years
26ending on the June 30 prior to the report. The report shall



10300HB1384ham001- 37 -LRB103 25389 BMS 57786 a

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



10300HB1384ham001- 38 -LRB103 25389 BMS 57786 a

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



10300HB1384ham001- 39 -LRB103 25389 BMS 57786 a

1otherwise eligible for medical assistance under this Article.
2As used in this Section, "opioid antagonist" means a drug that
3binds to opioid receptors and blocks or inhibits the effect of
4opioids acting on those receptors, including, but not limited
5to, naloxone hydrochloride or any other similarly acting drug
6approved by the U.S. Food and Drug Administration. The
7Department shall not impose a copayment on the coverage
8provided for naloxone hydrochloride under the medical
9assistance program.
10    Upon federal approval, the Department shall provide
11coverage and reimbursement for all drugs that are approved for
12marketing by the federal Food and Drug Administration and that
13are recommended by the federal Public Health Service or the
14United States Centers for Disease Control and Prevention for
15pre-exposure prophylaxis and related pre-exposure prophylaxis
16services, including, but not limited to, HIV and sexually
17transmitted infection screening, treatment for sexually
18transmitted infections, medical monitoring, assorted labs, and
19counseling to reduce the likelihood of HIV infection among
20individuals who are not infected with HIV but who are at high
21risk of HIV infection.
22    A federally qualified health center, as defined in Section
231905(l)(2)(B) of the federal Social Security Act, shall be
24reimbursed by the Department in accordance with the federally
25qualified health center's encounter rate for services provided
26to medical assistance recipients that are performed by a



10300HB1384ham001- 40 -LRB103 25389 BMS 57786 a

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



10300HB1384ham001- 41 -LRB103 25389 BMS 57786 a

1    Notwithstanding any other provision of this Code, within
212 months after June 2, 2022 (the effective date of Public Act
3102-1037) this amendatory Act of the 102nd General Assembly
4and subject to federal approval, acupuncture services
5performed by an acupuncturist licensed under the Acupuncture
6Practice Act who is acting within the scope of his or her
7license shall be covered under the medical assistance program.
8The Department shall apply for any federal waiver or State
9Plan amendment, if required, to implement this paragraph. The
10Department may adopt any rules, including standards and
11criteria, necessary to implement this paragraph.
12    Notwithstanding any other provision of this Code,
13medically necessary reconstructive services that are intended
14to restore physical appearance shall be covered under the
15medical assistance program for persons who are otherwise
16eligible for medical assistance under this Article. As used in
17this paragraph, "reconstructive services" means treatments
18performed on structures of the body damaged by trauma to
19restore physical appearance.
20(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
21102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
2235, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
2355-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
24102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
251-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
26102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.



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11-1-23; revised 2-5-23.)".