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305 ILCS 5/5-5.24
(305 ILCS 5/5-5.24)
Prenatal and perinatal care.
(a) The Department of
Healthcare and Family Services may provide reimbursement under this Article for all prenatal and
perinatal health care services that are provided for the purpose of preventing
low-birthweight infants, reducing the need for neonatal intensive care hospital
services, and promoting perinatal and maternal health. These services may include
comprehensive risk assessments for pregnant individuals, individuals with infants, and
infants, lactation counseling, nutrition counseling, childbirth support,
psychosocial counseling, treatment and prevention of periodontal disease, language translation, nurse home visitation, and
that have been proven to improve birth and maternal health outcomes.
maximize the use of preventive prenatal and perinatal health care services
federal statutes, rules, and regulations.
The Department of Public Aid (now Department of Healthcare and Family Services)
shall develop a plan for prenatal and perinatal preventive
health care and
shall present the plan to the General Assembly by January 1, 2004.
On or before January 1, 2006 and
every 2 years
thereafter, the Department shall report to the General Assembly concerning the
effectiveness of prenatal and perinatal health care services reimbursed under
in preventing low-birthweight infants and reducing the need for neonatal
hospital services. Each such report shall include an evaluation of how the
expenditures for treating
low-birthweight infants compared with the investment in promoting healthy
infants in local community areas throughout Illinois relates to healthy infant
in those areas.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(b)(1) As used in this subsection:
"Affiliated provider" means a provider who is enrolled in the medical assistance program and has an active contract with a managed care organization.
"Non-affiliated provider" means a provider who is enrolled in the medical assistance program but does not have a contract with an MCO.
"Preventive prenatal and perinatal health care services" means services described in subsection (a) including the following non-emergent diagnostic and ancillary services:
(i) Diagnostic labs and imaging, including level II
(ii) RhoGAM injections.
(iii) Injectable 17-alpha-hydroxyprogesterone
caproate (commonly called 17P).
(iv) Intrapartum (labor and delivery) services.
(v) Any other outpatient or inpatient service
relating to pregnancy or the 12 months following childbirth or fetal loss.
(2) In order to maximize the accessibility of preventive prenatal and perinatal health care services, the Department of Healthcare and Family Services shall amend its managed care contracts such that an MCO must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid under the Illinois Medicaid fee-for-service program methodology for such services, including all policy adjusters, including, but not limited to, Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates, unless a different rate was agreed upon by the health plan and the non-affiliated provider.
(3) In cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the requirements under paragraph (2) shall not apply if the services were not emergency services, as defined in Section 5-30.1, and:
(A) the non-affiliated provider is a perinatal
hospital and has, within the 12 months preceding the date of service, rejected a contract that was offered in good faith by the health plan as determined by the Department; or
(B) the health plan has terminated a contract with
the non-affiliated provider for cause, and the Department has not deemed the termination to have been without merit. The Department may deem that a determination for cause has merit if:
(i) an institutional provider has repeatedly
failed to conduct discharge planning; or
(ii) the provider's conduct adversely and
substantially impacts the health of Medicaid patients; or
(iii) the provider's conduct constitutes fraud,
(iv) the provider's conduct violates the code of
ethics governing his or her profession.
(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23