(305 ILCS 5/5-30.16) Sec. 5-30.16. Medicaid Business Opportunity Commission. (a) The Medicaid Business Opportunity Commission is
created within the Department of Healthcare and Family Services
to develop a program to support and grow minority, women, and persons with disability owned businesses. (b) The Commission shall consist of the following members: (1) Two members appointed by the Illinois Legislative |
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(2) Two members appointed by the Illinois Legislative
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(3) Two members appointed by the Conference of Women
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| Legislators of the Illinois General Assembly.
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(4) Two members representing a statewide Medicaid
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| health plan association, appointed by the Governor.
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(5) One member representing the Department of
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| Healthcare and Family Services, appointed by the Governor.
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(6) Three members representing businesses currently
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| registered with the Business Enterprise Program, appointed by the Governor.
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(7) One member representing the disability
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| community, appointed by the Governor.
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(8) One member representing the Business Enterprise
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| Council, appointed by the Governor.
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(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.
(f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(g) The Commission shall:
(1) Develop a recommendation on a Medicaid Business
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| Opportunity Program for Minority, Women, and Persons with Disability Owned business contracting requirements to be included in the contracts between the Department of Healthcare and Family Services and the Managed Care entities for the provision of Medicaid Services.
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(2) Make recommendations on the process by which
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| vendors or providers would be certified as eligible to be included in the program and appropriate eligibility standards relative to the healthcare industry.
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(3) Make a recommendation on whether to include not
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| for profit organizations, diversity councils, or diversity chambers as eligible for certification.
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(4) Make a recommendation on whether diverse staff
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| shall be considered within the goals set for managed care entities.
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(5) Make a recommendation on whether a new platform
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| for certification is necessary to administer this program or if the existing platform for the Business Enterprise Program is capable of including recommended changes coming from this Commission.
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(6) Make a recommendation on the ongoing activity of
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| the Commission including structure, frequency of meetings, and agendas to ensure ongoing oversight of the program by the Commission.
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(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.
(i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
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(305 ILCS 5/5-30.17) Sec. 5-30.17. Medicaid Managed Care Oversight Commission. (a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program. (b) The Commission shall consist of the following members: (1) One member of the Senate, appointed by the |
| Senate President, who shall serve as co-chair.
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(2) One member of the House of Representatives,
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| appointed by the Speaker of the House of Representatives, who shall serve as co-chair.
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(3) One member of the House of Representatives,
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| appointed by the Minority Leader of the House of Representatives.
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(4) One member of the Senate, appointed by the
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(5) One member representing the Department of
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| Healthcare and Family Services, appointed by the Governor.
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(6) One member representing the Department of
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| Public Health, appointed by the Governor.
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(7) One member representing the Department of Human
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| Services, appointed by the Governor.
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(8) One member representing the Department of
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| Children and Family Services, appointed by the Governor.
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(9) One member of a statewide association
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| representing Medicaid managed care plans, appointed by the Governor.
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(10) One member of a statewide association
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| representing a majority of hospitals, appointed by the Governor.
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(11) Two academic experts on Medicaid managed care
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| programs, appointed by the Governor.
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(12) One member of a statewide association
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| representing primary care providers, appointed by the Governor.
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(13) One member of a statewide association
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| representing behavioral health providers, appointed by the Governor.
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(14) Members representing Federally Qualified Health
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| Centers, a long-term care association, a dental association, pharmacies, pharmacists, a developmental disability association, a Medicaid consumer advocate, a Medicaid consumer, an association representing physicians, a behavioral health association, and an association representing pediatricians, appointed by the Governor.
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(15) A member of a statewide association representing
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| only safety-net hospitals, appointed by the Governor.
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(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(f) The Commission shall:
(1) review data on health outcomes of Medicaid
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(2) review current care coordination and case
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| management efforts and make recommendations on expanding care coordination to additional populations with a focus on the social determinants of health;
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(3) review and assess the appropriateness of
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| metrics used in the Pay-for-Performance programs;
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(4) review the Department's prior authorization and
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| utilization management requirements and recommend adaptations for the Medicaid population;
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(5) review managed care performance in meeting
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| diversity contracting goals and the use of funds dedicated to meeting such goals, including, but not limited to, contracting requirements set forth in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act; recommend strategies to increase compliance with diversity contracting goals in collaboration with the Chief Procurement Officer for General Services and the Business Enterprise Council for Minorities, Women, and Persons with Disabilities; and recoup any misappropriated funds for diversity contracting;
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(6) review data on the effectiveness of
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| processing to medical providers;
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(7) review member access to health care services in
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| the Medicaid Program, including specialty care services;
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(8) review value-based and other alternative
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| payment methodologies to make recommendations to enhance program efficiency and improve health outcomes;
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(9) review the compliance of all managed care
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| entities in State contracts and recommend reasonable financial penalties for any noncompliance;
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(10) produce an annual report detailing the
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| Commission's findings based upon its review of research conducted under this Section, including specific recommendations, if any, and any other information the Commission may deem proper in furtherance of its duties under this Section;
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(11) review provider availability and make
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| recommendations to increase providers where needed, including reviewing the regulatory environment and making recommendations for reforms;
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(12) review capacity for culturally competent
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| services, including translation services among providers; and
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(13) review and recommend changes to the safety-net
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| hospital definition to create different classifications of safety-net hospitals.
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(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing.
(g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
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(305 ILCS 5/5-36) Sec. 5-36. Pharmacy benefits. (a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law. (2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies: (A) the Department shall approve any contract between |
| a third-party administrator and a pharmacy;
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(B) the Department's third-party administrator shall
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| not change the terms of a contract between a third-party administrator and a pharmacy without written approval by the Department; and
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(C) the Department's third-party administrator shall
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| not create, modify, implement, or indirectly establish any fee on a pharmacy, pharmacist, or a recipient of medical assistance without written approval by the Department.
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(b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5).
(b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with Section 513b2 of the Illinois Insurance Code.
(c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section.
(d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department.
(e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information:
(1) whether the pharmacy benefit manager has a
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| contract, agreement, or other arrangement with a pharmaceutical manufacturer to exclusively dispense or provide a drug to a managed care organization's enrollees, and the aggregate amounts of consideration of economic benefits collected or received pursuant to that arrangement;
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(2) the percentage of claims payments made by the
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| pharmacy benefit manager to pharmacies owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly held companies;
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(3) the aggregate amount of the fees or assessments
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| imposed on, or collected from, pharmacy providers; and
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(4) the average annualized percentage of revenue
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| collected by the pharmacy benefit manager as a result of each contract it has executed with a managed care organization contracted by the Department to provide medical assistance benefits which is not paid by the pharmacy benefit manager to pharmacy providers and pharmaceutical manufacturers or labelers or in order to perform administrative functions pursuant to its contracts with managed care organizations.
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(f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made
available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable.
(g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
(h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider:
(1) a provision prohibiting the provider from
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| informing a patient of a less costly alternative to a prescribed medication; or
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(2) a provision that prohibits the provider from
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| dispensing a particular amount of a prescribed medication, if the pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.
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(h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B entity or 340B pharmacy a provision that:
(1) imposes any fee, chargeback, or rate adjustment
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| that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
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(2) imposes any fee, chargeback, or rate adjustment
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| that exceeds the fee, chargeback, or rate adjustment that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
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(3) prevents or interferes with an individual's
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| choice to receive a prescription drug from a 340B entity or 340B pharmacy through any legally permissible means;
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(4) excludes a 340B entity or 340B pharmacy from a
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| pharmacy network on the basis of whether the 340B entity or 340B pharmacy participates in the 340B drug discount program;
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(5) prevents a 340B entity or 340B pharmacy from
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| using a drug purchased under the 340B drug discount program so long as the drug recipient is a patient of the 340B entity; nothing in this Section exempts a 340B pharmacy from following the Department's preferred drug list or from any prior approval requirements of the Department or the Medicaid managed care organization that are imposed on the drug for all pharmacies; or
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(6) any other provision that discriminates against a
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| 340B entity or 340B pharmacy by treating a 340B entity or 340B pharmacy differently than non-340B entities or non-340B pharmacies for any reason relating to the entity's participation in the 340B drug discount program.
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A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
In this subsection (h-5):
"340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program.
"340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
(i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager.
(j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department.
(k) The Department shall adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
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(305 ILCS 5/5-37) Sec. 5-37. Billing mechanism for preventive mental health services delivered to children. (a) The General Assembly finds: (1) It is common for children to have mental health |
| needs but to not have a full-blown diagnosis of a mental illness. Examples include, but are not limited to, children who have mild or emerging symptoms of a mental health condition (such as meeting some but not all the criteria for a diagnosis, including, but not limited to, symptoms of depression, attentional deficits, anxiety or prodromal symptoms of bipolar disorder or schizophrenia); cutting or engaging in other forms of self-harm; or experiencing violence or trauma).
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(2) The federal requirement that Medicaid-covered
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| children have access to Early and Periodic Screening, Diagnostic and Treatment services includes ensuring that Medicaid-covered children who have a mental health need but do not have a mental health diagnosis have access to treatment.
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(3) The Department of Healthcare and Family Services'
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| existing policy acknowledges this federal requirement by allowing for Medicaid billing for mental health services for children who have a need for services but who do not have a mental health diagnosis in Section 207.3.3 of the Community-Based Behavioral Services Provider Handbook. However, the current policy of the Department of Healthcare and Family Services requires clinicians to specify a diagnosis code and make a notation in the child's medical record that the service is preventive. This effectively requires the clinician to associate a diagnosis with the child and is a major barrier for services because many clinicians rightly are unwilling to document a mental health diagnosis in the medical record when a diagnosis is not medically appropriate.
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(b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21 that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness. The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts. If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly. If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.
(Source: P.A. 101-461, eff. 1-1-20 .)
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(305 ILCS 5/5-40) Sec. 5-40. Human breast milk coverage. (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that |
| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
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(2) the infant's mother is medically or physically
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| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;
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(3) the milk has been determined to be medically
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| necessary for the infant; and
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(4) one or more of the following applies:
(A) the infant's birth weight is below 1,500
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(B) the infant has a congenital or acquired
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| condition that places the infant at a high risk for development of necrotizing enterocolitis;
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(C) the infant has infant hypoglycemia;
(D) the infant has congenital heart disease;
(E) the infant has had or will have an organ
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(F) the infant has sepsis; or
(G) the infant has any other serious congenital
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| or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.
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(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(1) the milk is obtained from a human milk bank that
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| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
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(2) the child's mother is medically or physically
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| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
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(3) the milk has been determined to be medically
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| necessary for the child; and
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(4) one or more of the following applies:
(A) the child has spinal muscular atrophy;
(B) the child's birth weight was below 1,500
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| grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;
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(C) the child has had or will have an organ
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(D) the child has a congenital or acquired
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| condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.
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(c) Notwithstanding any other provision of this Act,
pasteurized donated human breast milk, which may include human
milk fortifiers if indicated by a prescribing licensed medical
practitioner, shall be covered under a health plan for persons
who are otherwise eligible for coverage under this Act if the
covered person is a child 12 months of age or older, a licensed
medical practitioner prescribes the milk for the covered
person, and all of the following conditions are met:
(1) the milk is obtained from a human milk bank that
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| meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
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(2) the child's mother is medically or physically
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| unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
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(3) the milk has been determined to be medically
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| necessary for the child; and
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(4) the child has spinal muscular atrophy.
(Source: P.A. 101-511, eff. 1-1-20 .)
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(305 ILCS 5/5-44)
Sec. 5-44. Screening, Brief Intervention, and Referral to Treatment. As used in this Section, "SBIRT" means a comprehensive, integrated, public health approach to the delivery of early intervention and treatment
services for persons who are at risk of developing substance use disorders or have substance use disorders including, but not limited to, an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT services include all of the following: (1) Screening to quickly assess the severity of |
| substance use and to identify the appropriate level of treatment.
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(2) Brief intervention focused on increasing insight
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| and awareness regarding substance use and motivation toward behavioral change.
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(3) Referral to treatment provided to those
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| identified as needing more extensive treatment with access to specialty care.
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SBIRT services may include, but are not limited to, the following settings and programs: primary care centers, hospital emergency rooms, hospital in-patient units,
trauma centers, community behavioral health programs, and other community settings that provide opportunities for early intervention with at-risk substance users before more severe
consequences occur.
The Department of Healthcare and Family Services shall develop and seek federal approval of a SBIRT benefit for which
qualified providers shall be reimbursed under the medical assistance program.
In conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, the Department of Healthcare and
Family Services may develop a methodology and reimbursement rate for SBIRT services provided by qualified providers in approved
settings.
For opioid specific SBIRT services provided in a hospital emergency department, the Department of Healthcare and
Family Services shall develop a bundled reimbursement
methodology and rate for a package of opioid treatment services, which include initiation of medication for the treatment of opioid use disorder in
the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services when necessary. This
package of opioid related services shall be billed on a separate claim and shall be reimbursed outside of the Enhanced Ambulatory Patient
Grouping system.
(Source: P.A. 102-598, eff. 1-1-22; 102-813, eff. 5-13-22.)
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(305 ILCS 5/5-47) (Text of Section from P.A. 103-102) Sec. 5-47. Medicaid reimbursement rates; substance use disorder treatment providers and facilities. (a) Beginning on January 1, 2024, subject to federal approval, the Department of Healthcare and Family Services, in conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, shall provide a 30% increase in reimbursement rates for all Medicaid-covered ASAM Level 3 residential/inpatient substance use disorder treatment services. No existing or future reimbursement rates or add-ons shall be reduced or changed to address this proposed rate increase. No later than 3 months after the effective date of this amendatory Act of the 103rd General Assembly, the Department of Healthcare and Family Services shall submit any necessary application to the federal Centers for Medicare and Medicaid Services to implement the requirements of this Section. (b) Parity in community-based behavioral health rates; implementation plan for cost reporting. For the purpose of understanding behavioral health services cost structures and their impact on the Medical Assistance Program, the Department of Healthcare and Family Services shall engage stakeholders to develop a plan for the regular collection of cost reporting for all entity-based substance use disorder providers. Data shall be used to inform on the effectiveness and efficiency of Illinois Medicaid rates. The Department and stakeholders shall develop a plan by April 1, 2024. The Department shall engage stakeholders on implementation of the plan. The plan, at minimum, shall consider all of the following: (1) Alignment with certified community behavioral |
| health clinic requirements, standards, policies, and procedures.
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(2) Inclusion of prospective costs to measure what is
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| needed to increase services and capacity.
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(3) Consideration of differences in collection and
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| policies based on the size of providers.
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(4) Consideration of additional administrative time
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(5) Goals, purposes, and usage of data collected from
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(6) Inclusion of qualitative data in addition to
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(7) Technical assistance for providers for completing
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| cost reports including initial training by the Department for providers.
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(8) Implementation of a timeline which allows an
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| initial grace period for providers to adjust internal procedures and data collection.
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Details from collected cost reports shall be made publicly available on the Department's website and costs shall be used to ensure the effectiveness and efficiency of Illinois Medicaid rates.
(c) Reporting; access to substance use disorder treatment services and recovery supports. By no later than April 1, 2024, the Department of Healthcare and Family Services, with input from the Department of Human Services' Division of Substance Use Prevention and Recovery, shall submit a report to the General Assembly regarding access to treatment services and recovery supports for persons diagnosed with a substance use disorder. The report shall include, but is not limited to, the following information:
(1) The number of providers enrolled in the Illinois
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| Medical Assistance Program certified to provide substance use disorder treatment services, aggregated by ASAM level of care, and recovery supports.
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(2) The number of Medicaid customers in Illinois with
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| a diagnosed substance use disorder receiving substance use disorder treatment, aggregated by provider type and ASAM level of care.
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(3) A comparison of Illinois' substance use disorder
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| licensure and certification requirements with those of comparable state Medicaid programs.
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(4) Recommendations for and an analysis of the impact
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| of aligning reimbursement rates for outpatient substance use disorder treatment services with reimbursement rates for community-based mental health treatment services.
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(5) Recommendations for expanding substance use
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| disorder treatment to other qualified provider entities and licensed professionals of the healing arts. The recommendations shall include an analysis of the opportunities to maximize the flexibilities permitted by the federal Centers for Medicare and Medicaid Services for expanding access to the number and types of qualified substance use disorder providers.
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(Source: P.A. 103-102, eff. 6-16-23.)
(Text of Section from P.A. 103-243)
Sec. 5-47. Coverage for mental health and substance use disorder telehealth services.
(a) As used in this Section:
"Behavioral health care professional" has the meaning given to "health care professional" in Section 5 of the Telehealth Act, but only with respect to professionals licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services engaged in the delivery of mental health or substance use disorder treatment or services.
"Behavioral health facility" means a community mental health center, a behavioral health clinic, a substance use disorder treatment program, or a facility or provider licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services.
"Behavioral telehealth services" has the meaning given to the term "telehealth services" in Section 5 of the Telehealth Act, but limited solely to mental health and substance use disorder treatment or services to a patient, regardless of patient location.
"Distant site" has the meaning given to that term in Section 5 of the Telehealth Act.
"Originating site" has the meaning given to that term in Section 5 of the Telehealth Act.
(b) The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.
(c) To ensure behavioral telehealth services are equitably provided, coverage required under this Section shall comply with all of the following:
(1) The Department and any managed care plans under
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| contract with the Department for the medical assistance program shall not:
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(A) require that in-person contact occur between
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| a behavioral health care professional and a patient before the provision of a behavioral telehealth service;
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(B) require patients, behavioral health care
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| professionals, or behavioral health facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of behavioral telehealth services;
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(C) require the use of behavioral telehealth
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| services when the behavioral health care professional has determined that it is not appropriate;
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(D) require the use of behavioral telehealth
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| services when a patient chooses an in-person consultation;
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(E) require a behavioral health care professional
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| to be physically present in the same room as the patient at the originating site, unless deemed medically necessary by the behavioral health care professional providing the behavioral telehealth service;
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(F) create geographic or facility restrictions or
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| requirements for behavioral telehealth services;
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(G) require behavioral health care professionals
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| or behavioral health facilities to offer or provide behavioral telehealth services;
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(H) require patients to use behavioral telehealth
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| services or require patients to use a separate panel of behavioral health care professionals or behavioral health facilities to receive behavioral telehealth services; or
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(I) impose upon behavioral telehealth services
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| utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same behavioral health care service when rendered in-person, except that procedure code modifiers may be required to document behavioral telehealth.
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(2) Any cost sharing applicable to services provided
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| through behavioral telehealth shall not exceed the cost sharing required by the medical assistance program for the same services provided through in-person consultation.
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(3) The Department and any managed care plans under
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| contract with the Department for the medical assistance program shall notify behavioral health care professionals and behavioral health facilities of any instructions necessary to facilitate billing for behavioral telehealth services.
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(d) For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.
(e) Behavioral health care professionals and behavioral health facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a behavioral telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996, 42 CFR Part 2, and the Mental Health and Developmental Disabilities Confidentiality Act.
(f) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from providing benefits for other telehealth services.
(g) There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.
(h) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from establishing limits on the use of telehealth for a particular behavioral health service when the limits are consistent with generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care.
(i) The Department may adopt rules to implement the provisions of this Section.
(Source: P.A. 103-243, eff. 1-1-24.)
(Text of Section from P.A. 103-325)
Sec. 5-47. Proton beam therapy; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for proton beam therapy. As used in this Section, "proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells. "Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.
(Source: P.A. 103-325, eff. 1-1-24.)
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