Public Act 103-1040

SB3741 Enrolled LRB103 37781 RPS 67910 b

AN ACT concerning regulation.

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

represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by

changing Section 370c as follows:

(215 ILCS 5/370c) (from Ch. 73, par. 982c)

Sec. 370c. Mental and emotional disorders.

(a)(1) On and after January 1, 2022 (the effective date of

Public Act 102-579), every insurer that amends, delivers,

issues, or renews group accident and health policies providing

coverage for hospital or medical treatment or services for

illness on an expense-incurred basis shall provide coverage

for the medically necessary treatment of mental, emotional,

nervous, or substance use disorders or conditions consistent

with the parity requirements of Section 370c.1 of this Code.

(2) Each insured that is covered for mental, emotional,

nervous, or substance use disorders or conditions shall be

free to select the physician licensed to practice medicine in

all its branches, licensed clinical psychologist, licensed

clinical social worker, licensed clinical professional

counselor, licensed marriage and family therapist, licensed

speech-language pathologist, or other licensed or certified

professional at a program licensed pursuant to the Substance

Use Disorder Act of his or her choice to treat such disorders,

and the insurer shall pay the covered charges of such

physician licensed to practice medicine in all its branches,

licensed clinical psychologist, licensed clinical social

worker, licensed clinical professional counselor, licensed

marriage and family therapist, licensed speech-language

pathologist, or other licensed or certified professional at a

program licensed pursuant to the Substance Use Disorder Act up

to the limits of coverage, provided (i) the disorder or

condition treated is covered by the policy, and (ii) the

physician, licensed psychologist, licensed clinical social

worker, licensed clinical professional counselor, licensed

marriage and family therapist, licensed speech-language

pathologist, or other licensed or certified professional at a

program licensed pursuant to the Substance Use Disorder Act is

authorized to provide said services under the statutes of this

State and in accordance with accepted principles of his or her

profession.

(3) Insofar as this Section applies solely to licensed

clinical social workers, licensed clinical professional

counselors, licensed marriage and family therapists, licensed

speech-language pathologists, and other licensed or certified

professionals at programs licensed pursuant to the Substance

Use Disorder Act, those persons who may provide services to

individuals shall do so after the licensed clinical social

worker, licensed clinical professional counselor, licensed

marriage and family therapist, licensed speech-language

pathologist, or other licensed or certified professional at a

program licensed pursuant to the Substance Use Disorder Act

has informed the patient of the desirability of the patient

conferring with the patient's primary care physician.

(4) "Mental, emotional, nervous, or substance use disorder

or condition" means a condition or disorder that involves a

mental health condition or substance use disorder that falls

under any of the diagnostic categories listed in the mental

and behavioral disorders chapter of the current edition of the

World Health Organization's International Classification of

Disease or that is listed in the most recent version of the

American Psychiatric Association's Diagnostic and Statistical

Manual of Mental Disorders. "Mental, emotional, nervous, or

substance use disorder or condition" includes any mental

health condition that occurs during pregnancy or during the

postpartum period and includes, but is not limited to,

postpartum depression.

(5) Medically necessary treatment and medical necessity

determinations shall be interpreted and made in a manner that

is consistent with and pursuant to subsections (h) through

(t).

(b)(1) (Blank).

(2) (Blank).

(2.5) (Blank).

(3) Unless otherwise prohibited by federal law and

consistent with the parity requirements of Section 370c.1 of

this Code, the reimbursing insurer that amends, delivers,

issues, or renews a group or individual policy of accident and

health insurance, a qualified health plan offered through the

health insurance marketplace, or a provider of treatment of

mental, emotional, nervous, or substance use disorders or

conditions shall furnish medical records or other necessary

data that substantiate that initial or continued treatment is

at all times medically necessary. An insurer shall provide a

mechanism for the timely review by a provider holding the same

license and practicing in the same specialty as the patient's

provider, who is unaffiliated with the insurer, jointly

selected by the patient (or the patient's next of kin or legal

representative if the patient is unable to act for himself or

herself), the patient's provider, and the insurer in the event

of a dispute between the insurer and patient's provider

regarding the medical necessity of a treatment proposed by a

patient's provider. If the reviewing provider determines the

treatment to be medically necessary, the insurer shall provide

reimbursement for the treatment. Future contractual or

employment actions by the insurer regarding the patient's

provider may not be based on the provider's participation in

this procedure. Nothing prevents the insured from agreeing in

writing to continue treatment at his or her expense. When

making a determination of the medical necessity for a

treatment modality for mental, emotional, nervous, or

substance use disorders or conditions, an insurer must make

the determination in a manner that is consistent with the

manner used to make that determination with respect to other

diseases or illnesses covered under the policy, including an

appeals process. Medical necessity determinations for

substance use disorders shall be made in accordance with

appropriate patient placement criteria established by the

American Society of Addiction Medicine. No additional criteria

may be used to make medical necessity determinations for

substance use disorders.

(4) A group health benefit plan amended, delivered,

issued, or renewed on or after January 1, 2019 (the effective

date of Public Act 100-1024) or an individual policy of

accident and health insurance or a qualified health plan

offered through the health insurance marketplace amended,

delivered, issued, or renewed on or after January 1, 2019 (the

effective date of Public Act 100-1024):

(A) shall provide coverage based upon medical

necessity for the treatment of a mental, emotional,

nervous, or substance use disorder or condition consistent

with the parity requirements of Section 370c.1 of this

Code; provided, however, that in each calendar year

coverage shall not be less than the following:

(i) 45 days of inpatient treatment; and

(ii) beginning on June 26, 2006 (the effective

date of Public Act 94-921), 60 visits for outpatient

treatment including group and individual outpatient

treatment; and

(iii) for plans or policies delivered, issued for

delivery, renewed, or modified after January 1, 2007

(the effective date of Public Act 94-906), 20

additional outpatient visits for speech therapy for

treatment of pervasive developmental disorders that

will be in addition to speech therapy provided

pursuant to item (ii) of this subparagraph (A); and

(B) may not include a lifetime limit on the number of

days of inpatient treatment or the number of outpatient

visits covered under the plan.

(C) (Blank).

(5) An issuer of a group health benefit plan or an

individual policy of accident and health insurance or a

qualified health plan offered through the health insurance

marketplace may not count toward the number of outpatient

visits required to be covered under this Section an outpatient

visit for the purpose of medication management and shall cover

the outpatient visits under the same terms and conditions as

it covers outpatient visits for the treatment of physical

illness.

(5.5) An individual or group health benefit plan amended,

delivered, issued, or renewed on or after September 9, 2015

(the effective date of Public Act 99-480) shall offer coverage

for medically necessary acute treatment services and medically

necessary clinical stabilization services. The treating

provider shall base all treatment recommendations and the

health benefit plan shall base all medical necessity

determinations for substance use disorders in accordance with

the most current edition of the Treatment Criteria for

Addictive, Substance-Related, and Co-Occurring Conditions

established by the American Society of Addiction Medicine. The

treating provider shall base all treatment recommendations and

the health benefit plan shall base all medical necessity

determinations for medication-assisted treatment in accordance

with the most current Treatment Criteria for Addictive,

Substance-Related, and Co-Occurring Conditions established by

the American Society of Addiction Medicine.

As used in this subsection:

"Acute treatment services" means 24-hour medically

supervised addiction treatment that provides evaluation and

withdrawal management and may include biopsychosocial

assessment, individual and group counseling, psychoeducational

groups, and discharge planning.

"Clinical stabilization services" means 24-hour treatment,

usually following acute treatment services for substance

abuse, which may include intensive education and counseling

regarding the nature of addiction and its consequences,

relapse prevention, outreach to families and significant

others, and aftercare planning for individuals beginning to

engage in recovery from addiction.

(6) An issuer of a group health benefit plan may provide or

offer coverage required under this Section through a managed

care plan.

(6.5) An individual or group health benefit plan amended,

delivered, issued, or renewed on or after January 1, 2019 (the

effective date of Public Act 100-1024):

(A) shall not impose prior authorization requirements,

including limitations on dosage, other than those

established under the Treatment Criteria for Addictive,

Substance-Related, and Co-Occurring Conditions

established by the American Society of Addiction Medicine,

on a prescription medication approved by the United States

Food and Drug Administration that is prescribed or

administered for the treatment of substance use disorders;

(B) shall not impose any step therapy requirements,

other than those established under the Treatment Criteria

for Addictive, Substance-Related, and Co-Occurring

Conditions established by the American Society of

Addiction Medicine, before authorizing coverage for a

prescription medication approved by the United States Food

and Drug Administration that is prescribed or administered

for the treatment of substance use disorders;

(C) shall place all prescription medications approved

by the United States Food and Drug Administration

prescribed or administered for the treatment of substance

use disorders on, for brand medications, the lowest tier

of the drug formulary developed and maintained by the

individual or group health benefit plan that covers brand

medications and, for generic medications, the lowest tier

of the drug formulary developed and maintained by the

individual or group health benefit plan that covers

generic medications; and

(D) shall not exclude coverage for a prescription

medication approved by the United States Food and Drug

Administration for the treatment of substance use

disorders and any associated counseling or wraparound

services on the grounds that such medications and services

were court ordered.

(7) (Blank).

(8) (Blank).

(9) With respect to all mental, emotional, nervous, or

substance use disorders or conditions, coverage for inpatient

treatment shall include coverage for treatment in a

residential treatment center certified or licensed by the

Department of Public Health or the Department of Human

Services.

(c) This Section shall not be interpreted to require

coverage for speech therapy or other habilitative services for

those individuals covered under Section 356z.15 of this Code.

(d) With respect to a group or individual policy of

accident and health insurance or a qualified health plan

offered through the health insurance marketplace, the

Department and, with respect to medical assistance, the

Department of Healthcare and Family Services shall each

enforce the requirements of this Section and Sections 356z.23

and 370c.1 of this Code, the Paul Wellstone and Pete Domenici

Mental Health Parity and Addiction Equity Act of 2008, 42

U.S.C. 18031(j), and any amendments to, and federal guidance

or regulations issued under, those Acts, including, but not

limited to, final regulations issued under the Paul Wellstone

and Pete Domenici Mental Health Parity and Addiction Equity

Act of 2008 and final regulations applying the Paul Wellstone

and Pete Domenici Mental Health Parity and Addiction Equity

Act of 2008 to Medicaid managed care organizations, the

Children's Health Insurance Program, and alternative benefit

plans. Specifically, the Department and the Department of

Healthcare and Family Services shall take action:

(1) proactively ensuring compliance by individual and

group policies, including by requiring that insurers

submit comparative analyses, as set forth in paragraph (6)

of subsection (k) of Section 370c.1, demonstrating how

they design and apply nonquantitative treatment

limitations, both as written and in operation, for mental,

emotional, nervous, or substance use disorder or condition

benefits as compared to how they design and apply

nonquantitative treatment limitations, as written and in

operation, for medical and surgical benefits;

(2) evaluating all consumer or provider complaints

regarding mental, emotional, nervous, or substance use

disorder or condition coverage for possible parity

violations;

(3) performing parity compliance market conduct

examinations or, in the case of the Department of

Healthcare and Family Services, parity compliance audits

of individual and group plans and policies, including, but

not limited to, reviews of:

(A) nonquantitative treatment limitations,

including, but not limited to, prior authorization

requirements, concurrent review, retrospective review,

step therapy, network admission standards,

reimbursement rates, and geographic restrictions;

(B) denials of authorization, payment, and

coverage; and

(C) other specific criteria as may be determined

by the Department.

The findings and the conclusions of the parity compliance

market conduct examinations and audits shall be made public.

The Director may adopt rules to effectuate any provisions

of the Paul Wellstone and Pete Domenici Mental Health Parity

and Addiction Equity Act of 2008 that relate to the business of

insurance.

(e) Availability of plan information.

(1) The criteria for medical necessity determinations

made under a group health plan, an individual policy of

accident and health insurance, or a qualified health plan

offered through the health insurance marketplace with

respect to mental health or substance use disorder

benefits (or health insurance coverage offered in

connection with the plan with respect to such benefits)

must be made available by the plan administrator (or the

health insurance issuer offering such coverage) to any

current or potential participant, beneficiary, or

contracting provider upon request.

(2) The reason for any denial under a group health

benefit plan, an individual policy of accident and health

insurance, or a qualified health plan offered through the

health insurance marketplace (or health insurance coverage

offered in connection with such plan or policy) of

reimbursement or payment for services with respect to

mental, emotional, nervous, or substance use disorders or

conditions benefits in the case of any participant or

beneficiary must be made available within a reasonable

time and in a reasonable manner and in readily

understandable language by the plan administrator (or the

health insurance issuer offering such coverage) to the

participant or beneficiary upon request.

(f) As used in this Section, "group policy of accident and

health insurance" and "group health benefit plan" includes (1)

State-regulated employer-sponsored group health insurance

plans written in Illinois or which purport to provide coverage

for a resident of this State; and (2) State employee health

plans.

(g) (1) As used in this subsection:

"Benefits", with respect to insurers, means the benefits

provided for treatment services for inpatient and outpatient

treatment of substance use disorders or conditions at American

Society of Addiction Medicine levels of treatment 2.1

(Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1

(Clinically Managed Low-Intensity Residential), 3.3

(Clinically Managed Population-Specific High-Intensity

Residential), 3.5 (Clinically Managed High-Intensity

Residential), and 3.7 (Medically Monitored Intensive

Inpatient) and OMT (Opioid Maintenance Therapy) services.

"Benefits", with respect to managed care organizations,

means the benefits provided for treatment services for

inpatient and outpatient treatment of substance use disorders

or conditions at American Society of Addiction Medicine levels

of treatment 2.1 (Intensive Outpatient), 2.5 (Partial

Hospitalization), 3.5 (Clinically Managed High-Intensity

Residential), and 3.7 (Medically Monitored Intensive

Inpatient) and OMT (Opioid Maintenance Therapy) services.

"Substance use disorder treatment provider or facility"

means a licensed physician, licensed psychologist, licensed

psychiatrist, licensed advanced practice registered nurse, or

licensed, certified, or otherwise State-approved facility or

provider of substance use disorder treatment.

(2) A group health insurance policy, an individual health

benefit plan, or qualified health plan that is offered through

the health insurance marketplace, small employer group health

plan, and large employer group health plan that is amended,

delivered, issued, executed, or renewed in this State, or

approved for issuance or renewal in this State, on or after

January 1, 2019 (the effective date of Public Act 100-1023)

shall comply with the requirements of this Section and Section

370c.1. The services for the treatment and the ongoing

assessment of the patient's progress in treatment shall follow

the requirements of 77 Ill. Adm. Code 2060.

(3) Prior authorization shall not be utilized for the

benefits under this subsection. The substance use disorder

treatment provider or facility shall notify the insurer of the

initiation of treatment. For an insurer that is not a managed

care organization, the substance use disorder treatment

provider or facility notification shall occur for the

initiation of treatment of the covered person within 2

business days. For managed care organizations, the substance

use disorder treatment provider or facility notification shall

occur in accordance with the protocol set forth in the

provider agreement for initiation of treatment within 24

hours. If the managed care organization is not capable of

accepting the notification in accordance with the contractual

protocol during the 24-hour period following admission, the

substance use disorder treatment provider or facility shall

have one additional business day to provide the notification

to the appropriate managed care organization. Treatment plans

shall be developed in accordance with the requirements and

timeframes established in 77 Ill. Adm. Code 2060. If the

substance use disorder treatment provider or facility fails to

notify the insurer of the initiation of treatment in

accordance with these provisions, the insurer may follow its

normal prior authorization processes.

(4) For an insurer that is not a managed care

organization, if an insurer determines that benefits are no

longer medically necessary, the insurer shall notify the

covered person, the covered person's authorized

representative, if any, and the covered person's health care

provider in writing of the covered person's right to request

an external review pursuant to the Health Carrier External

Review Act. The notification shall occur within 24 hours

following the adverse determination.

Pursuant to the requirements of the Health Carrier

External Review Act, the covered person or the covered

person's authorized representative may request an expedited

external review. An expedited external review may not occur if

the substance use disorder treatment provider or facility

determines that continued treatment is no longer medically

necessary.

If an expedited external review request meets the criteria

of the Health Carrier External Review Act, an independent

review organization shall make a final determination of

medical necessity within 72 hours. If an independent review

organization upholds an adverse determination, an insurer

shall remain responsible to provide coverage of benefits

through the day following the determination of the independent

review organization. A decision to reverse an adverse

determination shall comply with the Health Carrier External

Review Act.

(5) The substance use disorder treatment provider or

facility shall provide the insurer with 7 business days'

advance notice of the planned discharge of the patient from

the substance use disorder treatment provider or facility and

notice on the day that the patient is discharged from the

substance use disorder treatment provider or facility.

(6) The benefits required by this subsection shall be

provided to all covered persons with a diagnosis of substance

use disorder or conditions. The presence of additional related

or unrelated diagnoses shall not be a basis to reduce or deny

the benefits required by this subsection.

(7) Nothing in this subsection shall be construed to

require an insurer to provide coverage for any of the benefits

in this subsection.

(h) As used in this Section:

"Generally accepted standards of mental, emotional,

nervous, or substance use disorder or condition care" means

standards of care and clinical practice that are generally

recognized by health care providers practicing in relevant

clinical specialties such as psychiatry, psychology, clinical

sociology, social work, addiction medicine and counseling, and

behavioral health treatment. Valid, evidence-based sources

reflecting generally accepted standards of mental, emotional,

nervous, or substance use disorder or condition care include

peer-reviewed scientific studies and medical literature,

recommendations of nonprofit health care provider professional

associations and specialty societies, including, but not

limited to, patient placement criteria and clinical practice

guidelines, recommendations of federal government agencies,

and drug labeling approved by the United States Food and Drug

Administration.

"Medically necessary treatment of mental, emotional,

nervous, or substance use disorders or conditions" means a

service or product addressing the specific needs of that

patient, for the purpose of screening, preventing, diagnosing,

managing, or treating an illness, injury, or condition or its

symptoms and comorbidities, including minimizing the

progression of an illness, injury, or condition or its

symptoms and comorbidities in a manner that is all of the

following:

(1) in accordance with the generally accepted

standards of mental, emotional, nervous, or substance use

disorder or condition care;

(2) clinically appropriate in terms of type,

frequency, extent, site, and duration; and

(3) not primarily for the economic benefit of the

insurer, purchaser, or for the convenience of the patient,

treating physician, or other health care provider.

"Utilization review" means either of the following:

(1) prospectively, retrospectively, or concurrently

reviewing and approving, modifying, delaying, or denying,

based in whole or in part on medical necessity, requests

by health care providers, insureds, or their authorized

representatives for coverage of health care services

before, retrospectively, or concurrently with the

provision of health care services to insureds.

(2) evaluating the medical necessity, appropriateness,

level of care, service intensity, efficacy, or efficiency

of health care services, benefits, procedures, or

settings, under any circumstances, to determine whether a

health care service or benefit subject to a medical

necessity coverage requirement in an insurance policy is

covered as medically necessary for an insured.

"Utilization review criteria" means patient placement

criteria or any criteria, standards, protocols, or guidelines

used by an insurer to conduct utilization review.

(i)(1) Every insurer that amends, delivers, issues, or

renews a group or individual policy of accident and health

insurance or a qualified health plan offered through the

health insurance marketplace in this State and Medicaid

managed care organizations providing coverage for hospital or

medical treatment on or after January 1, 2023 shall, pursuant

to subsections (h) through (s), provide coverage for medically

necessary treatment of mental, emotional, nervous, or

substance use disorders or conditions.

(2) An insurer shall not set a specific limit on the

duration of benefits or coverage of medically necessary

treatment of mental, emotional, nervous, or substance use

disorders or conditions or limit coverage only to alleviation

of the insured's current symptoms.

(3) All medical necessity determinations made by the

insurer concerning service intensity, level of care placement,

continued stay, and transfer or discharge of insureds

diagnosed with mental, emotional, nervous, or substance use

disorders or conditions shall be conducted in accordance with

the requirements of subsections (k) through (u).

(4) An insurer that authorizes a specific type of

treatment by a provider pursuant to this Section shall not

rescind or modify the authorization after that provider

renders the health care service in good faith and pursuant to

this authorization for any reason, including, but not limited

to, the insurer's subsequent cancellation or modification of

the insured's or policyholder's contract, or the insured's or

policyholder's eligibility. Nothing in this Section shall

require the insurer to cover a treatment when the

authorization was granted based on a material

misrepresentation by the insured, the policyholder, or the

provider. Nothing in this Section shall require Medicaid

managed care organizations to pay for services if the

individual was not eligible for Medicaid at the time the

service was rendered. Nothing in this Section shall require an

insurer to pay for services if the individual was not the

insurer's enrollee at the time services were rendered. As used

in this paragraph, "material" means a fact or situation that

is not merely technical in nature and results in or could

result in a substantial change in the situation.

(j) An insurer shall not limit benefits or coverage for

medically necessary services on the basis that those services

should be or could be covered by a public entitlement program,

including, but not limited to, special education or an

individualized education program, Medicaid, Medicare,

Supplemental Security Income, or Social Security Disability

Insurance, and shall not include or enforce a contract term

that excludes otherwise covered benefits on the basis that

those services should be or could be covered by a public

entitlement program. Nothing in this subsection shall be

construed to require an insurer to cover benefits that have

been authorized and provided for a covered person by a public

entitlement program. Medicaid managed care organizations are

not subject to this subsection.

(k) An insurer shall base any medical necessity

determination or the utilization review criteria that the

insurer, and any entity acting on the insurer's behalf,

applies to determine the medical necessity of health care

services and benefits for the diagnosis, prevention, and

treatment of mental, emotional, nervous, or substance use

disorders or conditions on current generally accepted

standards of mental, emotional, nervous, or substance use

disorder or condition care. All denials and appeals shall be

reviewed by a professional with experience or expertise

comparable to the provider requesting the authorization.

(l) For medical necessity determinations relating to level

of care placement, continued stay, and transfer or discharge

of insureds diagnosed with mental, emotional, and nervous

disorders or conditions, an insurer shall apply the patient

placement criteria set forth in the most recent version of the

treatment criteria developed by an unaffiliated nonprofit

professional association for the relevant clinical specialty

or, for Medicaid managed care organizations, patient placement

criteria determined by the Department of Healthcare and Family

Services that are consistent with generally accepted standards

of mental, emotional, nervous or substance use disorder or

condition care. Pursuant to subsection (b), in conducting

utilization review of all covered services and benefits for

the diagnosis, prevention, and treatment of substance use

disorders an insurer shall use the most recent edition of the

patient placement criteria established by the American Society

of Addiction Medicine.

(m) For medical necessity determinations relating to level

of care placement, continued stay, and transfer or discharge

that are within the scope of the sources specified in

subsection (l), an insurer shall not apply different,

additional, conflicting, or more restrictive utilization

review criteria than the criteria set forth in those sources.

For all level of care placement decisions, the insurer shall

authorize placement at the level of care consistent with the

assessment of the insured using the relevant patient placement

criteria as specified in subsection (l). If that level of

placement is not available, the insurer shall authorize the

next higher level of care. In the event of disagreement, the

insurer shall provide full detail of its assessment using the

relevant criteria as specified in subsection (l) to the

provider of the service and the patient.

Nothing in this subsection or subsection (l) prohibits an

insurer from applying utilization review criteria that were

developed in accordance with subsection (k) to health care

services and benefits for mental, emotional, and nervous

disorders or conditions that are not related to medical

necessity determinations for level of care placement,

continued stay, and transfer or discharge. If an insurer

purchases or licenses utilization review criteria pursuant to

this subsection, the insurer shall verify and document before

use that the criteria were developed in accordance with

subsection (k).

(n) In conducting utilization review that is outside the

scope of the criteria as specified in subsection (l) or

relates to the advancements in technology or in the types or

levels of care that are not addressed in the most recent

versions of the sources specified in subsection (l), an

insurer shall conduct utilization review in accordance with

subsection (k).

(o) This Section does not in any way limit the rights of a

patient under the Medical Patient Rights Act.

(p) This Section does not in any way limit early and

periodic screening, diagnostic, and treatment benefits as

defined under 42 U.S.C. 1396d(r).

(q) To ensure the proper use of the criteria described in

subsection (l), every insurer shall do all of the following:

(1) Educate the insurer's staff, including any third

parties contracted with the insurer to review claims,

conduct utilization reviews, or make medical necessity

determinations about the utilization review criteria.

(2) Make the educational program available to other

stakeholders, including the insurer's participating or

contracted providers and potential participants,

beneficiaries, or covered lives. The education program

must be provided at least once a year, in-person or

digitally, or recordings of the education program must be

made available to the aforementioned stakeholders.

(3) Provide, at no cost, the utilization review

criteria and any training material or resources to

providers and insured patients upon request. For

utilization review criteria not concerning level of care

placement, continued stay, and transfer or discharge used

by the insurer pursuant to subsection (m), the insurer may

place the criteria on a secure, password-protected website

so long as the access requirements of the website do not

unreasonably restrict access to insureds or their

providers. No restrictions shall be placed upon the

insured's or treating provider's access right to

utilization review criteria obtained under this paragraph

at any point in time, including before an initial request

for authorization.

(4) Track, identify, and analyze how the utilization

review criteria are used to certify care, deny care, and

support the appeals process.

(5) Conduct interrater reliability testing to ensure

consistency in utilization review decision making that

covers how medical necessity decisions are made; this

assessment shall cover all aspects of utilization review

as defined in subsection (h).

(6) Run interrater reliability reports about how the

clinical guidelines are used in conjunction with the

utilization review process and parity compliance

activities.

(7) Achieve interrater reliability pass rates of at

least 90% and, if this threshold is not met, immediately

provide for the remediation of poor interrater reliability

and interrater reliability testing for all new staff

before they can conduct utilization review without

supervision.

(8) Maintain documentation of interrater reliability

testing and the remediation actions taken for those with

pass rates lower than 90% and submit to the Department of

Insurance or, in the case of Medicaid managed care

organizations, the Department of Healthcare and Family

Services the testing results and a summary of remedial

actions as part of parity compliance reporting set forth

in subsection (k) of Section 370c.1.

(r) This Section applies to all health care services and

benefits for the diagnosis, prevention, and treatment of

mental, emotional, nervous, or substance use disorders or

conditions covered by an insurance policy, including

prescription drugs.

(s) This Section applies to an insurer that amends,

delivers, issues, or renews a group or individual policy of

accident and health insurance or a qualified health plan

offered through the health insurance marketplace in this State

providing coverage for hospital or medical treatment and

conducts utilization review as defined in this Section,

including Medicaid managed care organizations, and any entity

or contracting provider that performs utilization review or

utilization management functions on an insurer's behalf.

(t) If the Director determines that an insurer has

violated this Section, the Director may, after appropriate

notice and opportunity for hearing, by order, assess a civil

penalty between $1,000 and $5,000 for each violation. Moneys

collected from penalties shall be deposited into the Parity

Advancement Fund established in subsection (i) of Section

370c.1.

(u) An insurer shall not adopt, impose, or enforce terms

in its policies or provider agreements, in writing or in

operation, that undermine, alter, or conflict with the

requirements of this Section.

(v) The provisions of this Section are severable. If any

provision of this Section or its application is held invalid,

that invalidity shall not affect other provisions or

applications that can be given effect without the invalid

provision or application.

(Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22;

102-813, eff. 5-13-22; 103-426, eff. 8-4-23.)

Section 10. The Illinois Public Aid Code is amended by

changing Section 5-5 as follows:

(305 ILCS 5/5-5)

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 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 individuals, 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

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; (16.5) services performed by

a chiropractic physician licensed under the Medical Practice

Act of 1987 and acting within the scope of his or her license,

including, but not limited to, chiropractic manipulative

treatment; and (17) any other medical care, and any other type

of remedial care recognized under the laws of this State. 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

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 Section, all

tobacco cessation medications approved by the United States

Food and Drug Administration and all individual and group

tobacco cessation counseling services and telephone-based

counseling services and tobacco cessation medications provided

through the Illinois Tobacco Quitline shall be covered under

the medical assistance program for persons who are otherwise

eligible for assistance under this Article. The Department

shall comply with all federal requirements necessary to obtain

federal financial participation, as specified in 42 CFR

433.15(b)(7), for telephone-based counseling services provided

through the Illinois Tobacco Quitline, including, but not

limited to: (i) entering into a memorandum of understanding or

interagency agreement with the Department of Public Health, as

administrator of the Illinois Tobacco Quitline; and (ii)

developing a cost allocation plan for Medicaid-allowable

Illinois Tobacco Quitline services in accordance with 45 CFR

95.507. The Department shall submit the memorandum of

understanding or interagency agreement, the cost allocation

plan, and all other necessary documentation to the Centers for

Medicare and Medicaid Services for review and approval.

Coverage under this paragraph shall be contingent upon federal

approval.

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

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

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.

On and after January 1, 2022, the Department of Healthcare

and Family Services shall administer and regulate a

school-based dental program that allows for the out-of-office

delivery of preventative dental services in a school setting

to children under 19 years of age. The Department shall

establish, by rule, guidelines for participation by providers

and set requirements for follow-up referral care based on the

requirements established in the Dental Office Reference Manual

published by the Department that establishes the requirements

for dentists participating in the All Kids Dental School

Program. Every effort shall be made by the Department when

developing the program requirements to consider the different

geographic differences of both urban and rural areas of the

State for initial treatment and necessary follow-up care. No

provider shall be charged a fee by any unit of local government

to participate in the school-based dental program administered

by the Department. Nothing in this paragraph shall be

construed to limit or preempt a home rule unit's or school

district's authority to establish, change, or administer a

school-based dental program in addition to, or independent of,

the school-based dental program administered by the

Department.

The Illinois Department, by rule, may distinguish and

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

individuals 35 years of age or older who are eligible for

medical assistance under this Article, as follows:

(A) A baseline mammogram for individuals 35 to 39

years of age.

(B) An annual mammogram for individuals 40 years of

age or older.

(C) A mammogram at the age and intervals considered

medically necessary by the individual's health care

provider for individuals 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

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

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 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 and, after

January 1, 2023 (the effective date of Public Act 102-1018),

breast tomosynthesis.

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

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

individuals 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

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.

The Department shall provide coverage and reimbursement

for a human papillomavirus (HPV) vaccine that is approved for

marketing by the federal Food and Drug Administration for all

persons between the ages of 9 and 45. Subject to federal

approval, the Department shall provide coverage and

reimbursement for a human papillomavirus (HPV) vaccine for

persons of the age of 46 and above who have been diagnosed with

cervical dysplasia with a high risk of recurrence or

progression. The Department shall disallow any

preauthorization requirements for the administration of the

human papillomavirus (HPV) vaccine.

On or after July 1, 2022, individuals who are otherwise

eligible for medical assistance under this Article shall

receive coverage for perinatal depression screenings for the

12-month period beginning on the last day of their pregnancy.

Medical assistance coverage under this paragraph shall be

conditioned on the use of a screening instrument approved by

the Department.

Any medical or health care provider shall immediately

recommend, to any pregnant individual 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 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 individuals under this Code shall receive information

from the Department on the availability of services under any

program providing case management services for addicted

individuals, including information on appropriate referrals

for other social services that may be needed by addicted

individuals 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 the recipient's 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

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

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 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 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.

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

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 the category of risk

of the vendor.

Prior to enrollment and during the conditional enrollment

period in the medical assistance program, all vendors shall be

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

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 120

calendar days of receipt by the facility of required

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;

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

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-adjudicated, 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 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

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 the 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 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.

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.

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 fee for service and managed

care medical 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, or (4)

limitations on dosage.

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 or hospital fees related to the dispensing, distribution,

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. The

Department shall not impose a copayment on the coverage

provided for naloxone hydrochloride under the medical

assistance program.

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

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.

Within 90 days after October 8, 2021 (the effective date

of Public Act 102-665), the Department shall seek federal

approval of a State Plan amendment to expand coverage for

family planning services that includes presumptive eligibility

to individuals whose income is at or below 208% of the federal

poverty level. Coverage under this Section shall be effective

beginning no later than December 1, 2022.

Subject to approval by the federal Centers for Medicare

and Medicaid Services of a Title XIX State Plan amendment

electing the Program of All-Inclusive Care for the Elderly

(PACE) as a State Medicaid option, as provided for by Subtitle

I (commencing with Section 4801) of Title IV of the Balanced

Budget Act of 1997 (Public Law 105-33) and Part 460

(commencing with Section 460.2) of Subchapter E of Title 42 of

the Code of Federal Regulations, PACE program services shall

become a covered benefit of the medical assistance program,

subject to criteria established in accordance with all

applicable laws.

Notwithstanding any other provision of this Code,

community-based pediatric palliative care from a trained

interdisciplinary team shall be covered under the medical

assistance program as provided in Section 15 of the Pediatric

Palliative Care Act.

Notwithstanding any other provision of this Code, within

12 months after June 2, 2022 (the effective date of Public Act

102-1037) and subject to federal approval, acupuncture

services performed by an acupuncturist licensed under the

Acupuncture Practice Act who is acting within the scope of his

or her license shall be covered under the medical assistance

program. The Department shall apply for any federal waiver or

State Plan amendment, if required, to implement this

paragraph. The Department may adopt any rules, including

standards and criteria, necessary to implement this paragraph.

Notwithstanding any other provision of this Code, the

medical assistance program shall, subject to appropriation and

federal approval, reimburse hospitals for costs associated

with a newborn screening test for the presence of

metachromatic leukodystrophy, as required under the Newborn

Metabolic Screening Act, at a rate not less than the fee

charged by the Department of Public Health. The Department

shall seek federal approval before the implementation of the

newborn screening test fees by the Department of Public

Health.

Notwithstanding any other provision of this Code,

beginning on January 1, 2024, subject to federal approval,

cognitive assessment and care planning services provided to a

person who experiences signs or symptoms of cognitive

impairment, as defined by the Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition, 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,

medically necessary reconstructive services that are intended

to restore physical appearance shall be covered under the

medical assistance program for persons who are otherwise

eligible for medical assistance under this Article. As used in

this paragraph, "reconstructive services" means treatments

performed on structures of the body damaged by trauma to

restore physical appearance.

(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;

102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article

55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,

eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;

102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.

5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;

102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.

1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;

103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.

1-1-24; revised 12-15-23.)