101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB5226
 
Introduced , by Rep. Mary E. Flowers
 
SYNOPSIS AS INTRODUCED:





305 ILCS 5/5-5 from Ch. 23, par. 5-5

 Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, to address maternal mental health conditions and reduce the
incidence of maternal mortality and morbidity and postpartum
depression, pregnant women eligible to receive medical
assistance shall receive coverage for
prenatal and postnatal support services during pregnancy and
during the 24-month period beginning on the last day of the
pregnancy. Provides that prenatal and postnatal support services covered
under the medical assistance program include, but are not limited to, services
provided by doulas, lactation counselors, labor assistants,
childbirth educators, community mental health centers or
behavioral clinics, social workers, and public health nurses as well as any other evidence-based mental health and social care
services that are designed to screen, identify, and manage
maternal mental disorders. Permits the Department of Healthcare and Family Services to consult with the Department of Human Services and the Department of Public Health to establish a program of services consistent with the purposes of the amendatory Act. Requires the Department of Healthcare and Family Services to apply for any federal waiver or State Plan amendment required to implement the provisions of the amendatory Act. Requires the Department to adopt rules, upon federal approval, on certification or licensing requirements for providers of prenatal and postnatal support services and rules to provide medical assistance reimbursement for such services.



LRB101 17049 KTG 66449 b


FISCAL NOTE ACT MAY APPLY
 
 
A BILL FOR
 


HB5226LRB101 17049 KTG 66449 b



1 AN ACT concerning public aid.


2 Be it enacted by the People of the State of Illinois,

3represented in the General Assembly:



4 Section 5. The Illinois Public Aid Code is amended by 
5changing Section 5-5 as follows:



6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)


7 Sec. 5-5. Medical services.  The Illinois Department, by 
8rule, shall
determine the quantity and quality of and the rate 
9of reimbursement for the
medical assistance for which
payment 
10will be authorized, and the medical services to be provided,

11which may include all or part of the following: (1) inpatient 
12hospital
services; (2) outpatient hospital services; (3) other 
13laboratory and
X-ray services; (4) skilled nursing home 
14services; (5) physicians'
services whether furnished in the 
15office, the patient's home, a
hospital, a skilled nursing home, 
16or elsewhere; (6) medical care, or any
other type of remedial 
17care furnished by licensed practitioners; (7)
home health care 
18services; (8) private duty nursing service; (9) clinic

19services; (10) dental services, including prevention and 
20treatment of periodontal disease and dental caries disease for 
21pregnant women, provided by an individual licensed to practice 
22dentistry or dental surgery; for purposes of this item (10), 
23"dental services" means diagnostic, preventive, or corrective 
 
 
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1procedures provided by or under the supervision of a dentist in 
2the practice of his or her profession; (11) physical therapy 
3and related
services; (12) prescribed drugs, dentures, and 
4prosthetic devices; and
eyeglasses prescribed by a physician 
5skilled in the diseases of the eye,
or by an optometrist, 
6whichever the person may select; (13) other
diagnostic, 
7screening, preventive, and rehabilitative services, including 
8to ensure that the individual's need for intervention or 
9treatment of mental disorders or substance use disorders or 
10co-occurring mental health and substance use disorders is 
11determined using a uniform screening, assessment, and 
12evaluation process inclusive of criteria, for children and 
13adults; for purposes of this item (13), a uniform screening, 
14assessment, and evaluation process refers to a process that 
15includes an appropriate evaluation and, as warranted, a 
16referral; "uniform" does not mean the use of a singular 
17instrument, tool, or process that all must utilize; (14)

18transportation and such other expenses as may be necessary; 
19(15) medical
treatment of sexual assault survivors, as defined 
20in
Section 1a of the Sexual Assault Survivors Emergency 
21Treatment Act, for
injuries sustained as a result of the sexual 
22assault, including
examinations and laboratory tests to 
23discover evidence which may be used in
criminal proceedings 
24arising from the sexual assault; (16) the
diagnosis and 
25treatment of sickle cell anemia; and (17)
any other medical 
26care, and any other type of remedial care recognized
under the 
 
 
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1laws of this State. The term "any other type of remedial care" 
2shall
include nursing care and nursing home service for persons 
3who rely on
treatment by spiritual means alone through prayer 
4for healing.


5 Notwithstanding any other provision of this Section, a 
6comprehensive
tobacco use cessation program that includes 
7purchasing prescription drugs or
prescription medical devices 
8approved by the Food and Drug Administration shall
be covered 
9under the medical assistance
program under this Article for 
10persons who are otherwise eligible for
assistance under this 
11Article.


12 Notwithstanding any other provision of this Code, 
13reproductive health care that is otherwise legal in Illinois 
14shall be covered under the medical assistance program for 
15persons who are otherwise eligible for medical assistance under 
16this Article. 
17 Notwithstanding any other provision of this Code, the 
18Illinois
Department may not require, as a condition of payment 
19for any laboratory
test authorized under this Article, that a 
20physician's handwritten signature
appear on the laboratory 
21test order form. The Illinois Department may,
however, impose 
22other appropriate requirements regarding laboratory test
order 
23documentation.


24 Upon receipt of federal approval of an amendment to the 
25Illinois Title XIX State Plan for this purpose, the Department 
26shall authorize the Chicago Public Schools (CPS) to procure a 
 
 
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1vendor or vendors to manufacture eyeglasses for individuals 
2enrolled in a school within the CPS system. CPS shall ensure 
3that its vendor or vendors are enrolled as providers in the 
4medical assistance program and in any capitated Medicaid 
5managed care entity (MCE) serving individuals enrolled in a 
6school within the CPS system. Under any contract procured under 
7this provision, the vendor or vendors must serve only 
8individuals enrolled in a school within the CPS system. Claims 
9for services provided by CPS's vendor or vendors to recipients 
10of benefits in the medical assistance program under this Code, 
11the Children's Health Insurance Program, or the Covering ALL 
12KIDS Health Insurance Program shall be submitted to the 
13Department or the MCE in which the individual is enrolled for 
14payment and shall be reimbursed at the Department's or the 
15MCE's established rates or rate methodologies for eyeglasses. 
16 On and after July 1, 2012, the Department of Healthcare and 
17Family Services may provide the following services to
persons

18eligible for assistance under this Article who are 
19participating in
education, training or employment programs 
20operated by the Department of Human
Services as successor to 
21the Department of Public Aid:

22  (1) dental services provided by or under the 
23 supervision of a dentist; and


24  (2) eyeglasses prescribed by a physician skilled in the 
25 diseases of the
eye, or by an optometrist, whichever the 
26 person may select.

 
 
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1 On and after July 1, 2018, the Department of Healthcare and 
2Family Services shall provide dental services to any adult who 
3is otherwise eligible for assistance under the medical 
4assistance program. As used in this paragraph, "dental 
5services" means diagnostic, preventative, restorative, or 
6corrective procedures, including procedures and services for 
7the prevention and treatment of periodontal disease and dental 
8caries disease, provided by an individual who is licensed to 
9practice dentistry or dental surgery or who is under the 
10supervision of a dentist in the practice of his or her 
11profession.
12 On and after July 1, 2018, targeted dental services, as set 
13forth in Exhibit D of the Consent Decree entered by the United 
14States District Court for the Northern District of Illinois, 
15Eastern Division, in the matter of Memisovski v. Maram, Case 
16No. 92 C 1982, that are provided to adults under the medical 
17assistance program shall be established at no less than the 
18rates set forth in the "New Rate" column in Exhibit D of the 
19Consent Decree for targeted dental services that are provided 
20to persons under the age of 18 under the medical assistance 
21program. 
22 Notwithstanding any other provision of this Code and 
23subject to federal approval, the Department may adopt rules to 
24allow a dentist who is volunteering his or her service at no 
25cost to render dental services through an enrolled 
26not-for-profit health clinic without the dentist personally 
 
 
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1enrolling as a participating provider in the medical assistance 
2program. A not-for-profit health clinic shall include a public 
3health clinic or Federally Qualified Health Center or other 
4enrolled provider, as determined by the Department, through 
5which dental services covered under this Section are performed. 
6The Department shall establish a process for payment of claims 
7for reimbursement for covered dental services rendered under 
8this provision. 
9 The Illinois Department, by rule, may distinguish and 
10classify the
medical services to be provided only in accordance 
11with the classes of
persons designated in Section 5-2.


12 The Department of Healthcare and Family Services must 
13provide coverage and reimbursement for amino acid-based 
14elemental formulas, regardless of delivery method, for the 
15diagnosis and treatment of (i) eosinophilic disorders and (ii) 
16short bowel syndrome when the prescribing physician has issued 
17a written order stating that the amino acid-based elemental 
18formula is medically necessary.

19 The Illinois Department shall authorize the provision of, 
20and shall
authorize payment for, screening by low-dose 
21mammography for the presence of
occult breast cancer for women 
2235 years of age or older who are eligible
for medical 
23assistance under this Article, as follows:
24  (A) A baseline
mammogram for women 35 to 39 years of 
25 age.

26  (B) An annual mammogram for women 40 years of age or 
 
 
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1 older.
2  (C) A mammogram at the age and intervals considered 
3 medically necessary by the woman's health care provider for 
4 women under 40 years of age and having a family history of 
5 breast cancer, prior personal history of breast cancer, 
6 positive genetic testing, or other risk factors.
7  (D) A comprehensive ultrasound screening and MRI of an 
8 entire breast or breasts if a mammogram demonstrates 
9 heterogeneous or dense breast tissue or when medically 
10 necessary as determined by a physician licensed to practice 
11 medicine in all of its branches. 
12  (E) A screening MRI when medically necessary, as 
13 determined by a physician licensed to practice medicine in 
14 all of its branches. 
15  (F) A diagnostic mammogram when medically necessary, 
16 as determined by a physician licensed to practice medicine 
17 in all its branches, advanced practice registered nurse, or 
18 physician assistant. 
19 The Department shall not impose a deductible, coinsurance, 
20copayment, or any other cost-sharing requirement on the 
21coverage provided under this paragraph; except that this 
22sentence does not apply to coverage of diagnostic mammograms to 
23the extent such coverage would disqualify a high-deductible 
24health plan from eligibility for a health savings account 
25pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 
26223). 
 
 
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1 All screenings
shall
include a physical breast exam, 
2instruction on self-examination and
information regarding the 
3frequency of self-examination and its value as a
preventative 
4tool.
5  For purposes of this Section:
6 "Diagnostic
mammogram" means a mammogram obtained using 
7diagnostic mammography.
8 "Diagnostic
mammography" means a method of screening that 
9is designed to
evaluate an abnormality in a breast, including 
10an abnormality seen
or suspected on a screening mammogram or a 
11subjective or objective
abnormality otherwise detected in the 
12breast.
13 "Low-dose mammography" means
the x-ray examination of the 
14breast using equipment dedicated specifically
for mammography, 
15including the x-ray tube, filter, compression device,
and image 
16receptor, with an average radiation exposure delivery
of less 
17than one rad per breast for 2 views of an average size breast.

18The term also includes digital mammography and includes breast 
19tomosynthesis.
20 "Breast tomosynthesis" means a radiologic procedure that 
21involves the acquisition of projection images over the 
22stationary breast to produce cross-sectional digital 
23three-dimensional images of the breast.
24 If, at any time, the Secretary of the United States 
25Department of Health and Human Services, or its successor 
26agency, promulgates rules or regulations to be published in the 
 
 
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1Federal Register or publishes a comment in the Federal Register 
2or issues an opinion, guidance, or other action that would 
3require the State, pursuant to any provision of the Patient 
4Protection and Affordable Care Act (Public Law 111-148), 
5including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any 
6successor provision, to defray the cost of any coverage for 
7breast tomosynthesis outlined in this paragraph, then the 
8requirement that an insurer cover breast tomosynthesis is 
9inoperative other than any such coverage authorized under 
10Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and 
11the State shall not assume any obligation for the cost of 
12coverage for breast tomosynthesis set forth in this paragraph.

13 On and after January 1, 2016, the Department shall ensure 
14that all networks of care for adult clients of the Department 
15include access to at least one breast imaging Center of Imaging 
16Excellence as certified by the American College of Radiology.
17 On and after January 1, 2012, providers participating in a 
18quality improvement program approved by the Department shall be 
19reimbursed for screening and diagnostic mammography at the same 
20rate as the Medicare program's rates, including the increased 
21reimbursement for digital mammography.
22 The Department shall convene an expert panel including 
23representatives of hospitals, free-standing mammography 
24facilities, and doctors, including radiologists, to establish 
25quality standards for mammography.
26 On and after January 1, 2017, providers participating in a 
 
 
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1breast cancer treatment quality improvement program approved 
2by the Department shall be reimbursed for breast cancer 
3treatment at a rate that is no lower than 95% of the Medicare 
4program's rates for the data elements included in the breast 
5cancer treatment quality program.
6 The Department shall convene an expert panel, including 
7representatives of hospitals, free-standing breast cancer 
8treatment centers, breast cancer quality organizations, and 
9doctors, including breast surgeons, reconstructive breast 
10surgeons, oncologists, and primary care providers to establish 
11quality standards for breast cancer treatment.
12 Subject to federal approval, the Department shall 
13establish a rate methodology for mammography at federally 
14qualified health centers and other encounter-rate clinics. 
15These clinics or centers may also collaborate with other 
16hospital-based mammography facilities. By January 1, 2016, the 
17Department shall report to the General Assembly on the status 
18of the provision set forth in this paragraph.
19 The Department shall establish a methodology to remind 
20women who are age-appropriate for screening mammography, but 
21who have not received a mammogram within the previous 18 
22months, of the importance and benefit of screening mammography. 
23The Department shall work with experts in breast cancer 
24outreach and patient navigation to optimize these reminders and 
25shall establish a methodology for evaluating their 
26effectiveness and modifying the methodology based on the 
 
 
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1evaluation.
2 The Department shall establish a performance goal for 
3primary care providers with respect to their female patients 
4over age 40 receiving an annual mammogram. This performance 
5goal shall be used to provide additional reimbursement in the 
6form of a quality performance bonus to primary care providers 
7who meet that goal.
8 The Department shall devise a means of case-managing or 
9patient navigation for beneficiaries diagnosed with breast 
10cancer. This program shall initially operate as a pilot program 
11in areas of the State with the highest incidence of mortality 
12related to breast cancer. At least one pilot program site shall 
13be in the metropolitan Chicago area and at least one site shall 
14be outside the metropolitan Chicago area. On or after July 1, 
152016, the pilot program shall be expanded to include one site 
16in western Illinois, one site in southern Illinois, one site in 
17central Illinois, and 4 sites within metropolitan Chicago. An 
18evaluation of the pilot program shall be carried out measuring 
19health outcomes and cost of care for those served by the pilot 
20program compared to similarly situated patients who are not 
21served by the pilot program. 
22 The Department shall require all networks of care to 
23develop a means either internally or by contract with experts 
24in navigation and community outreach to navigate cancer 
25patients to comprehensive care in a timely fashion. The 
26Department shall require all networks of care to include access 
 
 
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1for patients diagnosed with cancer to at least one academic 
2commission on cancer-accredited cancer program as an 
3in-network covered benefit.
4 Any medical or health care provider shall immediately 
5recommend, to
any pregnant woman who is being provided prenatal 
6services and is suspected
of having a substance use disorder as 
7defined in the Substance Use Disorder Act, referral to a local 
8substance use disorder treatment program licensed by the 
9Department of Human Services or to a licensed
hospital which 
10provides substance abuse treatment services. The Department of 
11Healthcare and Family Services
shall assure coverage for the 
12cost of treatment of the drug abuse or
addiction for pregnant 
13recipients in accordance with the Illinois Medicaid
Program in 
14conjunction with the Department of Human Services.


15 All medical providers providing medical assistance to 
16pregnant women
under this Code shall receive information from 
17the Department on the
availability of services under any

18program providing case management services for addicted women,

19including information on appropriate referrals for other 
20social services
that may be needed by addicted women in 
21addition to treatment for addiction.


22 The Illinois Department, in cooperation with the 
23Departments of Human
Services (as successor to the Department 
24of Alcoholism and Substance
Abuse) and Public Health, through a 
25public awareness campaign, may
provide information concerning 
26treatment for alcoholism and drug abuse and
addiction, prenatal 
 
 
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1health care, and other pertinent programs directed at
reducing 
2the number of drug-affected infants born to recipients of 
3medical
assistance.


4 Neither the Department of Healthcare and Family Services 
5nor the Department of Human
Services shall sanction the 
6recipient solely on the basis of
her substance abuse.


7 The Illinois Department shall establish such regulations 
8governing
the dispensing of health services under this Article 
9as it shall deem
appropriate. The Department
should
seek the 
10advice of formal professional advisory committees appointed by

11the Director of the Illinois Department for the purpose of 
12providing regular
advice on policy and administrative matters, 
13information dissemination and
educational activities for 
14medical and health care providers, and
consistency in 
15procedures to the Illinois Department.


16 The Illinois Department may develop and contract with 
17Partnerships of
medical providers to arrange medical services 
18for persons eligible under
Section 5-2 of this Code. 
19Implementation of this Section may be by
demonstration projects 
20in certain geographic areas. The Partnership shall
be 
21represented by a sponsor organization. The Department, by rule, 
22shall
develop qualifications for sponsors of Partnerships. 
23Nothing in this
Section shall be construed to require that the 
24sponsor organization be a
medical organization.


25 The sponsor must negotiate formal written contracts with 
26medical
providers for physician services, inpatient and 
 
 
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1outpatient hospital care,
home health services, treatment for 
2alcoholism and substance abuse, and
other services determined 
3necessary by the Illinois Department by rule for
delivery by 
4Partnerships. Physician services must include prenatal and

5obstetrical care. The Illinois Department shall reimburse 
6medical services
delivered by Partnership providers to clients 
7in target areas according to
provisions of this Article and the 
8Illinois Health Finance Reform Act,
except that:


9  (1) Physicians participating in a Partnership and 
10 providing certain
services, which shall be determined by 
11 the Illinois Department, to persons
in areas covered by the 
12 Partnership may receive an additional surcharge
for such 
13 services.


14  (2) The Department may elect to consider and negotiate 
15 financial
incentives to encourage the development of 
16 Partnerships and the efficient
delivery of medical care.


17  (3) Persons receiving medical services through 
18 Partnerships may receive
medical and case management 
19 services above the level usually offered
through the 
20 medical assistance program.


21 Medical providers shall be required to meet certain 
22qualifications to
participate in Partnerships to ensure the 
23delivery of high quality medical
services. These 
24qualifications shall be determined by rule of the Illinois

25Department and may be higher than qualifications for 
26participation in the
medical assistance program. Partnership 
 
 
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1sponsors may prescribe reasonable
additional qualifications 
2for participation by medical providers, only with
the prior 
3written approval of the Illinois Department.


4 Nothing in this Section shall limit the free choice of 
5practitioners,
hospitals, and other providers of medical 
6services by clients.
In order to ensure patient freedom of 
7choice, the Illinois Department shall
immediately promulgate 
8all rules and take all other necessary actions so that
provided 
9services may be accessed from therapeutically certified 
10optometrists
to the full extent of the Illinois Optometric 
11Practice Act of 1987 without
discriminating between service 
12providers.


13 The Department shall apply for a waiver from the United 
14States Health
Care Financing Administration to allow for the 
15implementation of
Partnerships under this Section.


16 The Illinois Department shall require health care 
17providers to maintain
records that document the medical care 
18and services provided to recipients
of Medical Assistance under 
19this Article. Such records must be retained for a period of not 
20less than 6 years from the date of service or as provided by 
21applicable State law, whichever period is longer, except that 
22if an audit is initiated within the required retention period 
23then the records must be retained until the audit is completed 
24and every exception is resolved. The Illinois Department shall

25require health care providers to make available, when 
26authorized by the
patient, in writing, the medical records in a 
 
 
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1timely fashion to other
health care providers who are treating 
2or serving persons eligible for
Medical Assistance under this 
3Article. All dispensers of medical services
shall be required 
4to maintain and retain business and professional records

5sufficient to fully and accurately document the nature, scope, 
6details and
receipt of the health care provided to persons 
7eligible for medical
assistance under this Code, in accordance 
8with regulations promulgated by
the Illinois Department. The 
9rules and regulations shall require that proof
of the receipt 
10of prescription drugs, dentures, prosthetic devices and

11eyeglasses by eligible persons under this Section accompany 
12each claim
for reimbursement submitted by the dispenser of such 
13medical services.
No such claims for reimbursement shall be 
14approved for payment by the Illinois
Department without such 
15proof of receipt, unless the Illinois Department
shall have put 
16into effect and shall be operating a system of post-payment

17audit and review which shall, on a sampling basis, be deemed 
18adequate by
the Illinois Department to assure that such drugs, 
19dentures, prosthetic
devices and eyeglasses for which payment 
20is being made are actually being
received by eligible 
21recipients. Within 90 days after September 16, 1984 (the 
22effective date of Public Act 83-1439), the Illinois Department 
23shall establish a
current list of acquisition costs for all 
24prosthetic devices and any
other items recognized as medical 
25equipment and supplies reimbursable under
this Article and 
26shall update such list on a quarterly basis, except that
the 
 
 
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1acquisition costs of all prescription drugs shall be updated no

2less frequently than every 30 days as required by Section 
35-5.12.


4 Notwithstanding any other law to the contrary, the Illinois 
5Department shall, within 365 days after July 22, 2013 (the 
6effective date of Public Act 98-104), establish procedures to 
7permit skilled care facilities licensed under the Nursing Home 
8Care Act to submit monthly billing claims for reimbursement 
9purposes. Following development of these procedures, the 
10Department shall, by July 1, 2016, test the viability of the 
11new system and implement any necessary operational or 
12structural changes to its information technology platforms in 
13order to allow for the direct acceptance and payment of nursing 
14home claims. 
15 Notwithstanding any other law to the contrary, the Illinois 
16Department shall, within 365 days after August 15, 2014 (the 
17effective date of Public Act 98-963), establish procedures to 
18permit ID/DD facilities licensed under the ID/DD Community Care 
19Act and MC/DD facilities licensed under the MC/DD Act to submit 
20monthly billing claims for reimbursement purposes. Following 
21development of these procedures, the Department shall have an 
22additional 365 days to test the viability of the new system and 
23to ensure that any necessary operational or structural changes 
24to its information technology platforms are implemented. 
25 The Illinois Department shall require all dispensers of 
26medical
services, other than an individual practitioner or 
 
 
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1group of practitioners,
desiring to participate in the Medical 
2Assistance program
established under this Article to disclose 
3all financial, beneficial,
ownership, equity, surety or other 
4interests in any and all firms,
corporations, partnerships, 
5associations, business enterprises, joint
ventures, agencies, 
6institutions or other legal entities providing any
form of 
7health care services in this State under this Article.


8 The Illinois Department may require that all dispensers of 
9medical
services desiring to participate in the medical 
10assistance program
established under this Article disclose, 
11under such terms and conditions as
the Illinois Department may 
12by rule establish, all inquiries from clients
and attorneys 
13regarding medical bills paid by the Illinois Department, which

14inquiries could indicate potential existence of claims or liens 
15for the
Illinois Department.


16 Enrollment of a vendor
shall be
subject to a provisional 
17period and shall be conditional for one year. During the period 
18of conditional enrollment, the Department may
terminate the 
19vendor's eligibility to participate in, or may disenroll the 
20vendor from, the medical assistance
program without cause. 
21Unless otherwise specified, such termination of eligibility or 
22disenrollment is not subject to the
Department's hearing 
23process.
However, a disenrolled vendor may reapply without 
24penalty. 

25 The Department has the discretion to limit the conditional 
26enrollment period for vendors based upon category of risk of 
 
 
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1the vendor.
2 Prior to enrollment and during the conditional enrollment 
3period in the medical assistance program, all vendors shall be 
4subject to enhanced oversight, screening, and review based on 
5the risk of fraud, waste, and abuse that is posed by the 
6category of risk of the vendor. The Illinois Department shall 
7establish the procedures for oversight, screening, and review, 
8which may include, but need not be limited to: criminal and 
9financial background checks; fingerprinting; license, 
10certification, and authorization verifications; unscheduled or 
11unannounced site visits; database checks; prepayment audit 
12reviews; audits; payment caps; payment suspensions; and other 
13screening as required by federal or State law.
14 The Department shall define or specify the following: (i) 
15by provider notice, the "category of risk of the vendor" for 
16each type of vendor, which shall take into account the level of 
17screening applicable to a particular category of vendor under 
18federal law and regulations; (ii) by rule or provider notice, 
19the maximum length of the conditional enrollment period for 
20each category of risk of the vendor; and (iii) by rule, the 
21hearing rights, if any, afforded to a vendor in each category 
22of risk of the vendor that is terminated or disenrolled during 
23the conditional enrollment period. 
24 To be eligible for payment consideration, a vendor's 
25payment claim or bill, either as an initial claim or as a 
26resubmitted claim following prior rejection, must be received 
 
 
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1by the Illinois Department, or its fiscal intermediary, no 
2later than 180 days after the latest date on the claim on which 
3medical goods or services were provided, with the following 
4exceptions:
5  (1) In the case of a provider whose enrollment is in 
6 process by the Illinois Department, the 180-day period 
7 shall not begin until the date on the written notice from 
8 the Illinois Department that the provider enrollment is 
9 complete.
10  (2) In the case of errors attributable to the Illinois 
11 Department or any of its claims processing intermediaries 
12 which result in an inability to receive, process, or 
13 adjudicate a claim, the 180-day period shall not begin 
14 until the provider has been notified of the error.
15  (3) In the case of a provider for whom the Illinois 
16 Department initiates the monthly billing process.
17  (4) In the case of a provider operated by a unit of 
18 local government with a population exceeding 3,000,000 
19 when local government funds finance federal participation 
20 for claims payments. 
21 For claims for services rendered during a period for which 
22a recipient received retroactive eligibility, claims must be 
23filed within 180 days after the Department determines the 
24applicant is eligible. For claims for which the Illinois 
25Department is not the primary payer, claims must be submitted 
26to the Illinois Department within 180 days after the final 
 
 
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1adjudication by the primary payer.
2 In the case of long term care facilities, within 45 
3calendar days of receipt by the facility of required 
4prescreening information, new admissions with associated 
5admission documents shall be submitted through the Medical 
6Electronic Data Interchange (MEDI) or the Recipient 
7Eligibility Verification (REV) System or shall be submitted 
8directly to the Department of Human Services using required 
9admission forms. Effective September
1, 2014, admission 
10documents, including all prescreening
information, must be 
11submitted through MEDI or REV. Confirmation numbers assigned to 
12an accepted transaction shall be retained by a facility to 
13verify timely submittal. Once an admission transaction has been 
14completed, all resubmitted claims following prior rejection 
15are subject to receipt no later than 180 days after the 
16admission transaction has been completed.
17 Claims that are not submitted and received in compliance 
18with the foregoing requirements shall not be eligible for 
19payment under the medical assistance program, and the State 
20shall have no liability for payment of those claims.
21 To the extent consistent with applicable information and 
22privacy, security, and disclosure laws, State and federal 
23agencies and departments shall provide the Illinois Department 
24access to confidential and other information and data necessary 
25to perform eligibility and payment verifications and other 
26Illinois Department functions. This includes, but is not 
 
 
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1limited to: information pertaining to licensure; 
2certification; earnings; immigration status; citizenship; wage 
3reporting; unearned and earned income; pension income; 
4employment; supplemental security income; social security 
5numbers; National Provider Identifier (NPI) numbers; the 
6National Practitioner Data Bank (NPDB); program and agency 
7exclusions; taxpayer identification numbers; tax delinquency; 
8corporate information; and death records.
9 The Illinois Department shall enter into agreements with 
10State agencies and departments, and is authorized to enter into 
11agreements with federal agencies and departments, under which 
12such agencies and departments shall share data necessary for 
13medical assistance program integrity functions and oversight. 
14The Illinois Department shall develop, in cooperation with 
15other State departments and agencies, and in compliance with 
16applicable federal laws and regulations, appropriate and 
17effective methods to share such data. At a minimum, and to the 
18extent necessary to provide data sharing, the Illinois 
19Department shall enter into agreements with State agencies and 
20departments, and is authorized to enter into agreements with 
21federal agencies and departments, including, but not limited 
22to: the Secretary of State; the Department of Revenue; the 
23Department of Public Health; the Department of Human Services; 
24and the Department of Financial and Professional Regulation.
25 Beginning in fiscal year 2013, the Illinois Department 
26shall set forth a request for information to identify the 
 
 
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1benefits of a pre-payment, post-adjudication, and post-edit 
2claims system with the goals of streamlining claims processing 
3and provider reimbursement, reducing the number of pending or 
4rejected claims, and helping to ensure a more transparent 
5adjudication process through the utilization of: (i) provider 
6data verification and provider screening technology; and (ii) 
7clinical code editing; and (iii) pre-pay, pre- or 
8post-adjudicated predictive modeling with an integrated case 
9management system with link analysis. Such a request for 
10information shall not be considered as a request for proposal 
11or as an obligation on the part of the Illinois Department to 
12take any action or acquire any products or services. 
13 The Illinois Department shall establish policies, 
14procedures,
standards and criteria by rule for the acquisition, 
15repair and replacement
of orthotic and prosthetic devices and 
16durable medical equipment. Such
rules shall provide, but not be 
17limited to, the following services: (1)
immediate repair or 
18replacement of such devices by recipients; and (2) rental, 
19lease, purchase or lease-purchase of
durable medical equipment 
20in a cost-effective manner, taking into
consideration the 
21recipient's medical prognosis, the extent of the
recipient's 
22needs, and the requirements and costs for maintaining such

23equipment. Subject to prior approval, such rules shall enable a 
24recipient to temporarily acquire and
use alternative or 
25substitute devices or equipment pending repairs or

26replacements of any device or equipment previously authorized 
 
 
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1for such
recipient by the Department. Notwithstanding any 
2provision of Section 5-5f to the contrary, the Department may, 
3by rule, exempt certain replacement wheelchair parts from prior 
4approval and, for wheelchairs, wheelchair parts, wheelchair 
5accessories, and related seating and positioning items, 
6determine the wholesale price by methods other than actual 
7acquisition costs.
8 The Department shall require, by rule, all providers of 
9durable medical equipment to be accredited by an accreditation 
10organization approved by the federal Centers for Medicare and 
11Medicaid Services and recognized by the Department in order to 
12bill the Department for providing durable medical equipment to 
13recipients. No later than 15 months after the effective date of 
14the rule adopted pursuant to this paragraph, all providers must 
15meet the accreditation requirement.

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

24non-institutional services; and (ii) the establishment and 
25development of
non-institutional services in areas of the State 
26where they are not currently
available or are undeveloped; and 
 
 
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1(iii) notwithstanding any other provision of law, subject to 
2federal approval, on and after July 1, 2012, an increase in the 
3determination of need (DON) scores from 29 to 37 for applicants 
4for institutional and home and community-based long term care; 
5if and only if federal approval is not granted, the Department 
6may, in conjunction with other affected agencies, implement 
7utilization controls or changes in benefit packages to 
8effectuate a similar savings amount for this population; and 
9(iv) no later than July 1, 2013, minimum level of care 
10eligibility criteria for institutional and home and 
11community-based long term care; and (v) no later than October 
121, 2013, establish procedures to permit long term care 
13providers access to eligibility scores for individuals with an 
14admission date who are seeking or receiving services from the 
15long term care provider. In order to select the minimum level 
16of care eligibility criteria, the Governor shall establish a 
17workgroup that includes affected agency representatives and 
18stakeholders representing the institutional and home and 
19community-based long term care interests. This Section shall 
20not restrict the Department from implementing lower level of 
21care eligibility criteria for community-based services in 
22circumstances where federal approval has been granted.


23 The Illinois Department shall develop and operate, in 
24cooperation
with other State Departments and agencies and in 
25compliance with
applicable federal laws and regulations, 
26appropriate and effective
systems of health care evaluation and 
 
 
HB5226- 27 -LRB101 17049 KTG 66449 b


1programs for monitoring of
utilization of health care services 
2and facilities, as it affects
persons eligible for medical 
3assistance under this Code.


4 The Illinois Department shall report annually to the 
5General Assembly,
no later than the second Friday in April of 
61979 and each year
thereafter, in regard to:


7  (a) actual statistics and trends in utilization of 
8 medical services by
public aid recipients;


9  (b) actual statistics and trends in the provision of 
10 the various medical
services by medical vendors;


11  (c) current rate structures and proposed changes in 
12 those rate structures
for the various medical vendors; and


13  (d) efforts at utilization review and control by the 
14 Illinois Department.


15 The period covered by each report shall be the 3 years 
16ending on the June
30 prior to the report. The report shall 
17include suggested legislation
for consideration by the General 
18Assembly. The requirement for reporting to the General Assembly 
19shall be satisfied
by filing copies of the report as required 
20by Section 3.1 of the General Assembly Organization Act, and 
21filing such additional
copies
with the State Government Report 
22Distribution Center for the General
Assembly as is required 
23under paragraph (t) of Section 7 of the State
Library Act.


24 Rulemaking authority to implement Public Act 95-1045, if 
25any, is conditioned on the rules being adopted in accordance 
26with all provisions of the Illinois Administrative Procedure 
 
 
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1Act and all rules and procedures of the Joint Committee on 
2Administrative Rules; any purported rule not so adopted, for 
3whatever reason, is unauthorized. 
4 On and after July 1, 2012, the Department shall reduce any 
5rate of reimbursement for services or other payments or alter 
6any methodologies authorized by this Code to reduce any rate of 
7reimbursement for services or other payments in accordance with 
8Section 5-5e. 
9 Because kidney transplantation can be an appropriate, 
10cost-effective
alternative to renal dialysis when medically 
11necessary and notwithstanding the provisions of Section 1-11 of 
12this Code, beginning October 1, 2014, the Department shall 
13cover kidney transplantation for noncitizens with end-stage 
14renal disease who are not eligible for comprehensive medical 
15benefits, who meet the residency requirements of Section 5-3 of 
16this Code, and who would otherwise meet the financial 
17requirements of the appropriate class of eligible persons under 
18Section 5-2 of this Code. To qualify for coverage of kidney 
19transplantation, such person must be receiving emergency renal 
20dialysis services covered by the Department. Providers under 
21this Section shall be prior approved and certified by the 
22Department to perform kidney transplantation and the services 
23under this Section shall be limited to services associated with 
24kidney transplantation. 
25 Notwithstanding any other provision of this Code to the 
26contrary, on or after July 1, 2015, all FDA approved forms of 
 
 
HB5226- 29 -LRB101 17049 KTG 66449 b


1medication assisted treatment prescribed for the treatment of 
2alcohol dependence or treatment of opioid dependence shall be 
3covered under both fee for service and managed care medical 
4assistance programs for persons who are otherwise eligible for 
5medical assistance under this Article and shall not be subject 
6to any (1) utilization control, other than those established 
7under the American Society of Addiction Medicine patient 
8placement criteria,
(2) prior authorization mandate, or (3) 
9lifetime restriction limit
mandate. 
10 On or after July 1, 2015, opioid antagonists prescribed for 
11the treatment of an opioid overdose, including the medication 
12product, administration devices, and any pharmacy fees related 
13to the dispensing and administration of the opioid antagonist, 
14shall be covered under the medical assistance program for 
15persons who are otherwise eligible for medical assistance under 
16this Article. As used in this Section, "opioid antagonist" 
17means a drug that binds to opioid receptors and blocks or 
18inhibits the effect of opioids acting on those receptors, 
19including, but not limited to, naloxone hydrochloride or any 
20other similarly acting drug approved by the U.S. Food and Drug 
21Administration.
22 Upon federal approval, the Department shall provide 
23coverage and reimbursement for all drugs that are approved for 
24marketing by the federal Food and Drug Administration and that 
25are recommended by the federal Public Health Service or the 
26United States Centers for Disease Control and Prevention for 
 
 
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1pre-exposure prophylaxis and related pre-exposure prophylaxis 
2services, including, but not limited to, HIV and sexually 
3transmitted infection screening, treatment for sexually 
4transmitted infections, medical monitoring, assorted labs, and 
5counseling to reduce the likelihood of HIV infection among 
6individuals who are not infected with HIV but who are at high 
7risk of HIV infection.
8 A federally qualified health center, as defined in Section 
91905(l)(2)(B) of the federal
Social Security Act, shall be 
10reimbursed by the Department in accordance with the federally 
11qualified health center's encounter rate for services provided 
12to medical assistance recipients that are performed by a dental 
13hygienist, as defined under the Illinois Dental Practice Act, 
14working under the general supervision of a dentist and employed 
15by a federally qualified health center. 
16 To address maternal mental health conditions and reduce the 
17incidence of maternal mortality and morbidity and postpartum 
18depression, pregnant women eligible to receive medical 
19assistance under this Article shall receive coverage for 
20prenatal and postnatal support services during pregnancy and 
21during the 24-month period beginning on the last day of the 
22pregnancy. Prenatal and postnatal support services covered 
23under this paragraph include, but are not limited to, services 
24provided by doulas, lactation counselors, labor assistants, 
25childbirth educators, community mental health centers or 
26behavioral clinics, social workers, and public health nurses as 
 
 
HB5226- 31 -LRB101 17049 KTG 66449 b


1well as any other evidence-based mental health and social care 
2services that are designed to screen, identify, and manage 
3maternal mental disorders. The Department may consult with the 
4Department of Human Services and the Department of Public 
5Health to establish a program of services consistent with the 
6purposes of this paragraph. As used in this paragraph, "doula" 
7means a person certified to provide childbirth education and 
8support services, including emotional and physical support 
9provided during pregnancy, labor, birth, and postpartum. To be 
10eligible for reimbursement for doula services under this 
11paragraph, the individual providing doula services must: (i) be 
12certified by an entity that is nationally recognized for 
13training and certifying doulas and that is approved by the 
14Department; (ii) have completed a cultural competency course; 
15(iii) have completed a course on Health Insurance Portability 
16and Accountability Act compliance; (iv) be certified to perform 
17cardiopulmonary resuscitation; and (v) be willing to submit to 
18a federal and State criminal history background check. As used 
19in this paragraph, "cultural competency course" means training 
20in cultural sensitivity, cultural respect, and cultural 
21humility that instructs a doula on how to acquire and use 
22knowledge of the health-related beliefs, attitudes, practices, 
23and communication patterns of clients and their families to 
24improve services, strengthen programs, increase community 
25participation, and close the gaps in health status among 
26diverse population groups. The Department shall apply for any 
 
 
HB5226- 32 -LRB101 17049 KTG 66449 b


1federal waiver or State Plan amendment required to implement 
2this Section. Upon federal approval, the Department shall adopt 
3any rules necessary to implement the services covered under 
4this paragraph, including rules on certification or licensing 
5requirements for providers of prenatal and postnatal support 
6services and rules to provide medical assistance reimbursement 
7under this paragraph. 
8(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; 
9100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. 
106-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, 
11eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 
12100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. 
131-1-20; revised 9-18-19.)