Bill Text: IL HB4394 | 2019-2020 | 101st General Assembly | Introduced

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Bill Title: Amends the State Employees Group Insurance Act of 1971, the Illinois Public Aid Code, and the Problem Pregnancy Health Services and Care Act. Restores the provisions that were amended by Public Act 100-538 to the form in which they existed before their amendment by Public Act 100-538.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2020-01-29 - Referred to Rules Committee [HB4394 Detail]

Download: Illinois-2019-HB4394-Introduced.html

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101ST GENERAL ASSEMBLY State of Illinois 2019 and 2020 HB4394 Introduced , by Rep. Patrick Windhorst SYNOPSIS AS INTRODUCED:
5 ILCS 375/6 from Ch. 127, par. 526
5 ILCS 375/6.1 from Ch. 127, par. 526.1
305 ILCS 5/5-5 from Ch. 23, par. 5-5
305 ILCS 5/5-8 from Ch. 23, par. 5-8
305 ILCS 5/5-9 from Ch. 23, par. 5-9
305 ILCS 5/6-1 from Ch. 23, par. 6-1
410 ILCS 230/4-100 from Ch. 111 1/2, par. 4604-100
Amends the State Employees Group Insurance Act of 1971, the Illinois Public Aid Code, and the Problem Pregnancy Health Services and Care Act. Restores the provisions that were amended by Public Act 100-538 to the form in which they existed before their amendment by Public Act 100-538.
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FISCAL NOTE ACT MAY APPLY
A BILL FOR
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AN ACT concerning abortion.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The State Employees Group Insurance Act of 1971
is amended by changing Sections 6 and 6.1 as follows:
(5 ILCS 375/6) (from Ch. 127, par. 526)
Sec. 6. Program of health benefits.
(a) The program of health benefits shall provide for
protection against the financial costs of health care expenses
incurred in and out of hospital including basic
hospital-surgical-medical coverages. The program may include,
but shall not be limited to, such supplemental coverages as
out-patient diagnostic X-ray and laboratory expenses,
prescription drugs, dental services, hearing evaluations,
hearing aids, the dispensing and fitting of hearing aids, and
similar group benefits as are now or may become available.
However, nothing in this Act shall be construed to permit the
non-contributory portion of any such program to include the
expenses of obtaining an abortion, induced miscarriage or
induced premature birth unless, in the opinion of a physician,
such procedures are necessary for the preservation of the life
of the woman seeking such treatment, or except an induced
premature birth intended to produce a live viable child and

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such procedure is necessary for the health of the mother or the
unborn child. The program may also include coverage for those
who rely on treatment by prayer or spiritual means alone for
healing in accordance with the tenets and practice of a
recognized religious denomination.
The program of health benefits shall be designed by the
Director (1) to provide a reasonable relationship between the
benefits to be included and the expected distribution of
expenses of each such type to be incurred by the covered
members and dependents, (2) to specify, as covered benefits and
as optional benefits, the medical services of practitioners in
all categories licensed under the Medical Practice Act of 1987,
(3) to include reasonable controls, which may include
deductible and co-insurance provisions, applicable to some or
all of the benefits, or a coordination of benefits provision,
to prevent or minimize unnecessary utilization of the various
hospital, surgical and medical expenses to be provided and to
provide reasonable assurance of stability of the program, and
(4) to provide benefits to the extent possible to members
throughout the State, wherever located, on an equitable basis.
Notwithstanding any other provision of this Section or Act, for
all members or dependents who are eligible for benefits under
Social Security or the Railroad Retirement system or who had
sufficient Medicare-covered government employment, the
Department shall reduce benefits which would otherwise be paid
by Medicare, by the amount of benefits for which the member or

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dependents are eligible under Medicare, except that such
reduction in benefits shall apply only to those members or
dependents who (1) first become eligible for such medicare
coverage on or after the effective date of this amendatory Act
of 1992; or (2) are Medicare-eligible members or dependents of
a local government unit which began participation in the
program on or after July 1, 1992; or (3) remain eligible for
but no longer receive Medicare coverage which they had been
receiving on or after the effective date of this amendatory Act
of 1992.
Notwithstanding any other provisions of this Act, where a
covered member or dependents are eligible for benefits under
the federal Medicare health insurance program (Title XVIII of
the Social Security Act as added by Public Law 89-97, 89th
Congress), benefits paid under the State of Illinois program or
plan will be reduced by the amount of benefits paid by
Medicare. For members or dependents who are eligible for
benefits under Social Security or the Railroad Retirement
system or who had sufficient Medicare-covered government
employment, benefits shall be reduced by the amount for which
the member or dependent is eligible under Medicare, except that
such reduction in benefits shall apply only to those members or
dependents who (1) first become eligible for such Medicare
coverage on or after the effective date of this amendatory Act
of 1992; or (2) are Medicare-eligible members or dependents of
a local government unit which began participation in the

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program on or after July 1, 1992; or (3) remain eligible for,
but no longer receive Medicare coverage which they had been
receiving on or after the effective date of this amendatory Act
of 1992. Premiums may be adjusted, where applicable, to an
amount deemed by the Director to be reasonably consistent with
any reduction of benefits.
(b) A member, not otherwise covered by this Act, who has
retired as a participating member under Article 2 of the
Illinois Pension Code but is ineligible for the retirement
annuity under Section 2-119 of the Illinois Pension Code, shall
pay the premiums for coverage, not exceeding the amount paid by
the State for the non-contributory coverage for other members,
under the group health benefits program under this Act. The
Director shall determine the premiums to be paid by a member
under this subsection (b).
(Source: P.A. 100-538, eff. 1-1-18.)
(5 ILCS 375/6.1) (from Ch. 127, par. 526.1)
Sec. 6.1. The program of health benefits may offer as an
alternative, available on an optional basis, coverage through
health maintenance organizations. That part of the premium for
such coverage which is in excess of the amount which would
otherwise be paid by the State for the program of health
benefits shall be paid by the member who elects such
alternative coverage and shall be collected as provided for
premiums for other optional coverages.

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However, nothing in this Act shall be construed to permit
the noncontributory portion of any such program to include the
expenses of obtaining an abortion, induced miscarriage or
induced premature birth unless, in the opinion of a physician,
such procedures are necessary for the preservation of the life
of the woman seeking such treatment, or except an induced
premature birth intended to produce a live viable child and
such procedure is necessary for the health of the mother or her
unborn child.
(Source: P.A. 100-538, eff. 1-1-18.)
Section 10. The Illinois Public Aid Code is amended by
changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing home,
or elsewhere; (6) medical care, or any other type of remedial
care furnished by licensed practitioners; (7) home health care

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services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and
treatment of periodontal disease and dental caries disease for
pregnant women, provided by an individual licensed to practice
dentistry or dental surgery; for purposes of this item (10),
"dental services" means diagnostic, preventive, or corrective
procedures provided by or under the supervision of a dentist in
the practice of his or her profession; (11) physical therapy
and related services; (12) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician
skilled in the diseases of the eye, or by an optometrist,
whichever the person may select; (13) other diagnostic,
screening, preventive, and rehabilitative services, including
to ensure that the individual's need for intervention or
treatment of mental disorders or substance use disorders or
co-occurring mental health and substance use disorders is
determined using a uniform screening, assessment, and
evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency

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Treatment Act, for injuries sustained as a result of the sexual
assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; and (17) any other medical
care, and any other type of remedial care recognized under the
laws of this State, but not including abortions, or induced
miscarriages or premature births, unless, in the opinion of a
physician, such procedures are necessary for the preservation
of the life of the woman seeking such treatment, or except an
induced premature birth intended to produce a live viable child
and such procedure is necessary for the health of the mother or
her unborn child. The Illinois Department, by rule, shall
prohibit any physician from providing medical assistance to
anyone eligible therefor under this Code where such physician
has been found guilty of performing an abortion procedure in a
wilful and wanton manner upon a woman who was not pregnant at
the time such abortion procedure was performed. The term "any
other type of remedial care" shall include nursing care and
nursing home service for persons who rely on treatment by
spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for

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persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance under
this Article.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured under
this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients

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of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and
Family Services may provide the following services to persons
eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in the
diseases of the eye, or by an optometrist, whichever the
person may select.
On and after July 1, 2018, the Department of Healthcare and
Family Services shall provide dental services to any adult who
is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the

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supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as set
forth in Exhibit D of the Consent Decree entered by the United
States District Court for the Northern District of Illinois,
Eastern Division, in the matter of Memisovski v. Maram, Case
No. 92 C 1982, that are provided to adults under the medical
assistance program shall be established at no less than the
rates set forth in the "New Rate" column in Exhibit D of the
Consent Decree for targeted dental services that are provided
to persons under the age of 18 under the medical assistance
program.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical assistance
program. A not-for-profit health clinic shall include a public
health clinic or Federally Qualified Health Center or other
enrolled provider, as determined by the Department, through
which dental services covered under this Section are performed.
The Department shall establish a process for payment of claims
for reimbursement for covered dental services rendered under
this provision.
The Illinois Department, by rule, may distinguish and

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classify the medical services to be provided only in accordance
with the classes of persons designated in Section 5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
(A) A baseline mammogram for women 35 to 39 years of
age.
(B) An annual mammogram for women 40 years of age or
older.
(C) A mammogram at the age and intervals considered
medically necessary by the woman's health care provider for
women under 40 years of age and having a family history of
breast cancer, prior personal history of breast cancer,
positive genetic testing, or other risk factors.
(D) A comprehensive ultrasound screening and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically

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necessary as determined by a physician licensed to practice
medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse, or
physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms to
the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26 U.S.C.
223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including

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an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and image
receptor, with an average radiation exposure delivery of less
than one rad per breast for 2 views of an average size breast.
The term also includes digital mammography and includes breast
tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in the
Federal Register or publishes a comment in the Federal Register
or issues an opinion, guidance, or other action that would
require the State, pursuant to any provision of the Patient
Protection and Affordable Care Act (Public Law 111-148),
including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
successor provision, to defray the cost of any coverage for
breast tomosynthesis outlined in this paragraph, then the
requirement that an insurer cover breast tomosynthesis is
inoperative other than any such coverage authorized under

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Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
the State shall not assume any obligation for the cost of
coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of Imaging
Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall be
reimbursed for screening and diagnostic mammography at the same
rate as the Medicare program's rates, including the increased
reimbursement for digital mammography.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast

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surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening mammography.
The Department shall work with experts in breast cancer
outreach and patient navigation to optimize these reminders and
shall establish a methodology for evaluating their
effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast

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cancer. This program shall initially operate as a pilot program
in areas of the State with the highest incidence of mortality
related to breast cancer. At least one pilot program site shall
be in the metropolitan Chicago area and at least one site shall
be outside the metropolitan Chicago area. On or after July 1,
2016, the pilot program shall be expanded to include one site
in western Illinois, one site in southern Illinois, one site in
central Illinois, and 4 sites within metropolitan Chicago. An
evaluation of the pilot program shall be carried out measuring
health outcomes and cost of care for those served by the pilot
program compared to similarly situated patients who are not
served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include access
for patients diagnosed with cancer to at least one academic
commission on cancer-accredited cancer program as an
in-network covered benefit.
Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided prenatal
services and is suspected of having a substance use disorder as
defined in the Substance Use Disorder Act, referral to a local
substance use disorder treatment program licensed by the
Department of Human Services or to a licensed hospital which

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provides substance abuse treatment services. The Department of
Healthcare and Family Services shall assure coverage for the
cost of treatment of the drug abuse or addiction for pregnant
recipients in accordance with the Illinois Medicaid Program in
conjunction with the Department of Human Services.
All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under any
program providing case management services for addicted women,
including information on appropriate referrals for other
social services that may be needed by addicted women in
addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through a
public awareness campaign, may provide information concerning
treatment for alcoholism and drug abuse and addiction, prenatal
health care, and other pertinent programs directed at reducing
the number of drug-affected infants born to recipients of
medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the

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advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration projects
in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by rule,
shall develop qualifications for sponsors of Partnerships.
Nothing in this Section shall be construed to require that the
sponsor organization be a medical organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and the
Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and

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providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by the
Partnership may receive an additional surcharge for such
services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that provided
services may be accessed from therapeutically certified

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optometrists to the full extent of the Illinois Optometric
Practice Act of 1987 without discriminating between service
providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance under
this Article. Such records must be retained for a period of not
less than 6 years from the date of service or as provided by
applicable State law, whichever period is longer, except that
if an audit is initiated within the required retention period
then the records must be retained until the audit is completed
and every exception is resolved. The Illinois Department shall
require health care providers to make available, when
authorized by the patient, in writing, the medical records in a
timely fashion to other health care providers who are treating
or serving persons eligible for Medical Assistance under this
Article. All dispensers of medical services shall be required
to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope,
details and receipt of the health care provided to persons
eligible for medical assistance under this Code, in accordance
with regulations promulgated by the Illinois Department. The
rules and regulations shall require that proof of the receipt

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of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of such
medical services. No such claims for reimbursement shall be
approved for payment by the Illinois Department without such
proof of receipt, unless the Illinois Department shall have put
into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed
adequate by the Illinois Department to assure that such drugs,
dentures, prosthetic devices and eyeglasses for which payment
is being made are actually being received by eligible
recipients. Within 90 days after September 16, 1984 (the
effective date of Public Act 83-1439), the Illinois Department
shall establish a current list of acquisition costs for all
prosthetic devices and any other items recognized as medical
equipment and supplies reimbursable under this Article and
shall update such list on a quarterly basis, except that the
acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section
5-5.12.
The rules and regulations of the Illinois Department shall
require that a written statement including the required opinion
of a physician shall accompany any claim for reimbursement for
abortions, or induced miscarriages or premature births. This
statement shall indicate what procedures were used in providing
such medical services.

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Notwithstanding any other law to the contrary, the Illinois
Department shall, within 365 days after July 22, 2013 (the
effective date of Public Act 98-104), establish procedures to
permit skilled care facilities licensed under the Nursing Home
Care Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall, by July 1, 2016, test the viability of the
new system and implement any necessary operational or
structural changes to its information technology platforms in
order to allow for the direct acceptance and payment of nursing
home claims.
Notwithstanding any other law to the contrary, the Illinois
Department shall, within 365 days after August 15, 2014 (the
effective date of Public Act 98-963), establish procedures to
permit ID/DD facilities licensed under the ID/DD Community Care
Act and MC/DD facilities licensed under the MC/DD Act to submit
monthly billing claims for reimbursement purposes. Following
development of these procedures, the Department shall have an
additional 365 days to test the viability of the new system and
to ensure that any necessary operational or structural changes
to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other

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interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens
for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the period
of conditional enrollment, the Department may terminate the
vendor's eligibility to participate in, or may disenroll the
vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be

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subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following

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exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 45
calendar days of receipt by the facility of required

HB4394 - 26 - LRB101 16543 KTG 65927 b
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned to
an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has been
completed, all resubmitted claims following prior rejection
are subject to receipt no later than 180 days after the
admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data necessary
to perform eligibility and payment verifications and other
Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;

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employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies and departments shall share data necessary for
medical assistance program integrity functions and oversight.
The Illinois Department shall develop, in cooperation with
other State departments and agencies, and in compliance with
applicable federal laws and regulations, appropriate and
effective methods to share such data. At a minimum, and to the
extent necessary to provide data sharing, the Illinois
Department shall enter into agreements with State agencies and
departments, and is authorized to enter into agreements with
federal agencies and departments, including, but not limited
to: the Secretary of State; the Department of Revenue; the
Department of Public Health; the Department of Human Services;
and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or

HB4394 - 28 - LRB101 16543 KTG 65927 b
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the acquisition,
repair and replacement of orthotic and prosthetic devices and
durable medical equipment. Such rules shall provide, but not be
limited to, the following services: (1) immediate repair or
replacement of such devices by recipients; and (2) rental,
lease, purchase or lease-purchase of durable medical equipment
in a cost-effective manner, taking into consideration the
recipient's medical prognosis, the extent of the recipient's
needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a
recipient to temporarily acquire and use alternative or
substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized
for such recipient by the Department. Notwithstanding any
provision of Section 5-5f to the contrary, the Department may,
by rule, exempt certain replacement wheelchair parts from prior

HB4394 - 29 - LRB101 16543 KTG 65927 b
approval and, for wheelchairs, wheelchair parts, wheelchair
accessories, and related seating and positioning items,
determine the wholesale price by methods other than actual
acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date of
the rule adopted pursuant to this paragraph, all providers must
meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant cost
savings, the Department, or a managed care organization under
contract with the Department, may provide recipients or managed
care enrollees who have a prescription or Certificate of
Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping

HB4394 - 30 - LRB101 16543 KTG 65927 b
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the State
where they are not currently available or are undeveloped; and
(iii) notwithstanding any other provision of law, subject to
federal approval, on and after July 1, 2012, an increase in the
determination of need (DON) scores from 29 to 37 for applicants

HB4394 - 31 - LRB101 16543 KTG 65927 b
for institutional and home and community-based long term care;
if and only if federal approval is not granted, the Department
may, in conjunction with other affected agencies, implement
utilization controls or changes in benefit packages to
effectuate a similar savings amount for this population; and
(iv) no later than July 1, 2013, minimum level of care
eligibility criteria for institutional and home and
community-based long term care; and (v) no later than October
1, 2013, establish procedures to permit long term care
providers access to eligibility scores for individuals with an
admission date who are seeking or receiving services from the
long term care provider. In order to select the minimum level
of care eligibility criteria, the Governor shall establish a
workgroup that includes affected agency representatives and
stakeholders representing the institutional and home and
community-based long term care interests. This Section shall
not restrict the Department from implementing lower level of
care eligibility criteria for community-based services in
circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and
programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.

HB4394 - 32 - LRB101 16543 KTG 65927 b
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act, and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.

HB4394 - 33 - LRB101 16543 KTG 65927 b
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.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11 of
this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3 of
this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons under
Section 5-2 of this Code. To qualify for coverage of kidney
transplantation, such person must be receiving emergency renal
dialysis services covered by the Department. Providers under
this Section shall be prior approved and certified by the
Department to perform kidney transplantation and the services
under this Section shall be limited to services associated with
kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical

HB4394 - 34 - LRB101 16543 KTG 65927 b
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed for
the treatment of an opioid overdose, including the medication
product, administration devices, and any pharmacy fees related
to the dispensing and administration of the opioid antagonist,
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance under
this Article. As used in this Section, "opioid antagonist"
means a drug that binds to opioid receptors and blocks or
inhibits the effect of opioids acting on those receptors,
including, but not limited to, naloxone hydrochloride or any
other similarly acting drug approved by the U.S. Food and Drug
Administration.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually

HB4394 - 35 - LRB101 16543 KTG 65927 b
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a dental
hygienist, as defined under the Illinois Dental Practice Act,
working under the general supervision of a dentist and employed
by a federally qualified health center.
(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
1-1-20; revised 9-18-19.)
(305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
Sec. 5-8. Practitioners. In supplying medical assistance,
the Illinois Department may provide for the legally authorized
services of (i) persons licensed under the Medical Practice Act
of 1987, as amended, except as hereafter in this Section
stated, whether under a general or limited license, (ii)
persons licensed under the Nurse Practice Act as advanced

HB4394 - 36 - LRB101 16543 KTG 65927 b
practice registered nurses, regardless of whether or not the
persons have written collaborative agreements, (iii) persons
licensed or registered under other laws of this State to
provide dental, medical, pharmaceutical, optometric,
podiatric, or nursing services, or other remedial care
recognized under State law, (iv) persons licensed under other
laws of this State as a clinical social worker, and (v) persons
licensed under other laws of this State as physician
assistants. The Department shall adopt rules, no later than 90
days after January 1, 2017 (the effective date of Public Act
99-621), for the legally authorized services of persons
licensed under other laws of this State as a clinical social
worker. The Department may not provide for legally authorized
services of any physician who has been convicted of having
performed an abortion procedure in a wilful and wanton manner
on a woman who was not pregnant at the time such abortion
procedure was performed. The utilization of the services of
persons engaged in the treatment or care of the sick, which
persons are not required to be licensed or registered under the
laws of this State, is not prohibited by this Section.
(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17;
100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff.
1-1-18; 100-863, eff. 8-14-18.)
(305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
Sec. 5-9. Choice of medical dispensers. Applicants and

HB4394 - 37 - LRB101 16543 KTG 65927 b
recipients shall be entitled to free choice of those qualified
practitioners, hospitals, nursing homes, and other dispensers
of medical services meeting the requirements and complying with
the rules and regulations of the Illinois Department. However,
the Director of Healthcare and Family Services may, after
providing reasonable notice and opportunity for hearing, deny,
suspend or terminate any otherwise qualified person, firm,
corporation, association, agency, institution, or other legal
entity, from participation as a vendor of goods or services
under the medical assistance program authorized by this Article
if the Director finds such vendor of medical services in
violation of this Act or the policy or rules and regulations
issued pursuant to this Act. Any physician who has been
convicted of performing an abortion procedure in a wilful and
wanton manner upon a woman who was not pregnant at the time
such abortion procedure was performed shall be automatically
removed from the list of physicians qualified to participate as
a vendor of medical services under the medical assistance
program authorized by this Article.
(Source: P.A. 100-538, eff. 1-1-18.)
(305 ILCS 5/6-1) (from Ch. 23, par. 6-1)
Sec. 6-1. Eligibility requirements. Financial aid in
meeting basic maintenance requirements shall be given under
this Article to or in behalf of persons who meet the
eligibility conditions of Sections 6-1.1 through 6-1.10. In

HB4394 - 38 - LRB101 16543 KTG 65927 b
addition, each unit of local government subject to this Article
shall provide persons receiving financial aid in meeting basic
maintenance requirements with financial aid for either (a)
necessary treatment, care, and supplies required because of
illness or disability, or (b) acute medical treatment, care,
and supplies only. If a local governmental unit elects to
provide financial aid for acute medical treatment, care, and
supplies only, the general types of acute medical treatment,
care, and supplies for which financial aid is provided shall be
specified in the general assistance rules of the local
governmental unit, which rules shall provide that financial aid
is provided, at a minimum, for acute medical treatment, care,
or supplies necessitated by a medical condition for which prior
approval or authorization of medical treatment, care, or
supplies is not required by the general assistance rules of the
Illinois Department. Nothing in this Article shall be construed
to permit the granting of financial aid where the purpose of
such aid is to obtain an abortion, induced miscarriage or
induced premature birth unless, in the opinion of a physician,
such procedures are necessary for the preservation of the life
of the woman seeking such treatment, or except an induced
premature birth intended to produce a live viable child and
such procedure is necessary for the health of the mother or her
unborn child.
(Source: P.A. 100-538, eff. 1-1-18.)

HB4394 - 39 - LRB101 16543 KTG 65927 b
Section 15. The Problem Pregnancy Health Services and Care
Act is amended by changing Section 4-100 as follows:
(410 ILCS 230/4-100) (from Ch. 111 1/2, par. 4604-100)
Sec. 4-100. The Department may make grants to nonprofit
agencies and organizations which do not use such grants to
refer or counsel for, or perform, abortions and which
coordinate and establish linkages among services that will
further the purposes of this Act and, where appropriate, will
provide, supplement, or improve the quality of such services.
(Source: P.A. 100-538, eff. 1-1-18.)