104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026
HB4215

Introduced , by Rep. Diane Blair-Sherlock

SYNOPSIS AS INTRODUCED:

`20 ILCS 2310/2310-90`	`was 20 ILCS 2310/55.09`
`30 ILCS 500/1-10`
`305 ILCS 5/5-5`
`410 ILCS 240/Act title`
`410 ILCS 240/0.01`	`from Ch. 111 1/2, par. 4902.9`
`410 ILCS 240/2`	`from Ch. 111 1/2, par. 4904`
`410 ILCS 513/30`

Amends the Newborn Metabolic Screening Act. Changes the short title of the Act to the Newborn Screening Act. Specifies that, for purposes of the Act, hearing disorders are a genetic, metabolic, or congenital anomaly for which newborns must be screened. Provides that, beginning July 1, 2026, the base fee for newborn screening services shall be $165. Provides that 22% of the base fee must be allocated to the Department of Public Health for the Early Hearing Detection and Intervention Program. Provides that other State and federal funds for expenses related to metabolic, hearing, or congenital disorder screening, follow-up, and treatment programs (rather than only metabolic screening, follow-up, and treatment programs) may also be placed in the Metabolic Screening and Treatment Fund. In provisions concerning the temporary testing of all blood and biological specimens, excludes hearing screenings. Makes conforming and technical changes to the title of the Act, the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois, the Illinois Procurement Code, the Illinois Public Aid Code, and the Genetic Information Privacy Act. Effective immediately.

LRB104 15597 BDA 28764 b

A BILL FOR

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1 AN ACT concerning health.

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

3 represented in the General Assembly:

4 Section 5. The Department of Public Health Powers and

5 Duties Law of the Civil Administrative Code of Illinois is

6 amended by changing Section 2310-90 as follows:

7 (20 ILCS 2310/2310-90) (was 20 ILCS 2310/55.09)

8 Sec. 2310-90. Laboratories; fees; Public Health Laboratory

9 Services Revolving Fund. To maintain physical, chemical,

10 bacteriological, and biological laboratories; to make

11 examinations of milk, water, atmosphere, sewage, wastes, and

12 other substances, and equipment and processes relating

13 thereto; to make diagnostic tests for diseases and tests for

14 the evaluation of health hazards considered necessary for the

15 protection of the people of the State; and to assess a

16 reasonable fee for services provided as established by

17 regulation, under the Illinois Administrative Procedure Act,

18 which shall not exceed the Department's actual costs to

19 provide these services.

20 Excepting fees collected under the Newborn ~~Metabolic~~

21 Screening Act and the Lead Poisoning Prevention Act, all fees

22 shall be deposited into the Public Health Laboratory Services

23 Revolving Fund. Other State and federal funds related to

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1 laboratory services may also be deposited into the Fund, and

2 all interest that accrues on the moneys in the Fund shall be

3 deposited into the Fund.

4 Moneys shall be appropriated from the Fund solely for the

5 purposes of testing specimens submitted in support of

6 Department programs established for the protection of human

7 health, welfare, and safety, and for testing specimens

8 submitted by physicians and other health care providers, to

9 determine whether chemically hazardous, biologically

10 infectious substances, or other disease causing conditions are

11 present.

12 (Source: P.A. 96-328, eff. 8-11-09.)

13 Section 10. The Illinois Procurement Code is amended by

14 changing Section 1-10 as follows:

15 (30 ILCS 500/1-10)

16 Sec. 1-10. Application.

17 (a) This Code applies only to procurements for which

18 bidders, offerors, potential contractors, or contractors were

19 first solicited on or after July 1, 1998. This Code shall not

20 be construed to affect or impair any contract, or any

21 provision of a contract, entered into based on a solicitation

22 prior to the implementation date of this Code as described in

23 Article 99, including, but not limited to, any covenant

24 entered into with respect to any revenue bonds or similar

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1 instruments. All procurements for which contracts are

2 solicited between the effective date of Articles 50 and 99 and

3 July 1, 1998 shall be substantially in accordance with this

4 Code and its intent.

5 (b) This Code shall apply regardless of the source of the

6 funds with which the contracts are paid, including federal

7 assistance moneys. This Code shall not apply to:

8 (1) Contracts between the State and its political

9 subdivisions or other governments, or between State

10 governmental bodies, except as specifically provided in

11 this Code.

12 (2) Grants, except for the filing requirements of

13 Section 20-80.

14 (3) Purchase of care, except as provided in Section

15 5-30.6 of the Illinois Public Aid Code and this Section.

16 (4) Hiring of an individual as an employee and not as

17 an independent contractor, whether pursuant to an

18 employment code or policy or by contract directly with

19 that individual.

20 (5) Collective bargaining contracts.

21 (6) Purchase of real estate, except that notice of

22 this type of contract with a value of more than $25,000

23 must be published in the Procurement Bulletin within 10

24 calendar days after the deed is recorded in the county of

25 jurisdiction. The notice shall identify the real estate

26 purchased, the names of all parties to the contract, the

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1 value of the contract, and the effective date of the

2 contract.

3 (7) Contracts necessary to prepare for anticipated

4 litigation, enforcement actions, or investigations,

5 provided that the chief legal counsel to the Governor

6 shall give his or her prior approval when the procuring

7 agency is one subject to the jurisdiction of the Governor,

8 and provided that the chief legal counsel of any other

9 procuring entity subject to this Code shall give his or

10 her prior approval when the procuring entity is not one

11 subject to the jurisdiction of the Governor.

12 (8) (Blank).

13 (9) Procurement expenditures by the Illinois

14 Conservation Foundation when only private funds are used.

15 (10) (Blank).

16 (11) Public-private agreements entered into according

17 to the procurement requirements of Section 20 of the

18 Public-Private Partnerships for Transportation Act and

19 design-build agreements entered into according to the

20 procurement requirements of Section 25 of the

21 Public-Private Partnerships for Transportation Act.

22 (12) (A) Contracts for legal, financial, and other

23 professional and artistic services entered into by the

24 Illinois Finance Authority in which the State of Illinois

25 is not obligated. Such contracts shall be awarded through

26 a competitive process authorized by the members of the

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1 Illinois Finance Authority and are subject to Sections

2 5-30, 20-160, 50-13, 50-20, 50-35, and 50-37 of this Code,

3 as well as the final approval by the members of the

4 Illinois Finance Authority of the terms of the contract.

5 (B) Contracts for legal and financial services entered

6 into by the Illinois Housing Development Authority in

7 connection with the issuance of bonds in which the State

8 of Illinois is not obligated. Such contracts shall be

9 awarded through a competitive process authorized by the

10 members of the Illinois Housing Development Authority and

11 are subject to Sections 5-30, 20-160, 50-13, 50-20, 50-35,

12 and 50-37 of this Code, as well as the final approval by

13 the members of the Illinois Housing Development Authority

14 of the terms of the contract.

15 (13) Contracts for services, commodities, and

16 equipment to support the delivery of timely forensic

17 science services in consultation with and subject to the

18 approval of the Chief Procurement Officer as provided in

19 subsection (d) of Section 5-4-3a of the Unified Code of

20 Corrections, except for the requirements of Sections

21 20-60, 20-65, 20-70, and 20-160 and Article 50 of this

22 Code; however, the Chief Procurement Officer may, in

23 writing with justification, waive any certification

24 required under Article 50 of this Code. For any contracts

25 for services which are currently provided by members of a

26 collective bargaining agreement, the applicable terms of

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1 the collective bargaining agreement concerning

2 subcontracting shall be followed.

3 On and after January 1, 2019, this paragraph (13),

4 except for this sentence, is inoperative.

5 (14) Contracts for participation expenditures required

6 by a domestic or international trade show or exhibition of

7 an exhibitor, member, or sponsor.

8 (15) Contracts with a railroad or utility that

9 requires the State to reimburse the railroad or utilities

10 for the relocation of utilities for construction or other

11 public purpose. Contracts included within this paragraph

12 (15) shall include, but not be limited to, those

13 associated with: relocations, crossings, installations,

14 and maintenance. For the purposes of this paragraph (15),

15 "railroad" means any form of non-highway ground

16 transportation that runs on rails or electromagnetic

17 guideways and "utility" means: (1) public utilities as

18 defined in Section 3-105 of the Public Utilities Act, (2)

19 telecommunications carriers as defined in Section 13-202

20 of the Public Utilities Act, (3) electric cooperatives as

21 defined in Section 3.4 of the Electric Supplier Act, (4)

22 telephone or telecommunications cooperatives as defined in

23 Section 13-212 of the Public Utilities Act, (5) rural

24 water or waste water systems with 10,000 connections or

25 less, (6) a holder as defined in Section 21-201 of the

26 Public Utilities Act, and (7) municipalities owning or

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1 operating utility systems consisting of public utilities

2 as that term is defined in Section 11-117-2 of the

3 Illinois Municipal Code.

4 (16) Procurement expenditures necessary for the

5 Department of Public Health to provide the delivery of

6 timely newborn screening services in accordance with the

7 Newborn ~~Metabolic~~ Screening Act.

8 (17) Procurement expenditures necessary for the

9 Department of Agriculture, the Department of Financial and

10 Professional Regulation, the Department of Human Services,

11 and the Department of Public Health to implement the

12 Compassionate Use of Medical Cannabis Program and Opioid

13 Alternative Pilot Program requirements and ensure access

14 to medical cannabis for patients with debilitating medical

15 conditions in accordance with the Compassionate Use of

16 Medical Cannabis Program Act.

17 (18) This Code does not apply to any procurements

18 necessary for the Department of Agriculture, the

19 Department of Financial and Professional Regulation, the

20 Department of Human Services, the Department of Commerce

21 and Economic Opportunity, and the Department of Public

22 Health to implement the Cannabis Regulation and Tax Act if

23 the applicable agency has made a good faith determination

24 that it is necessary and appropriate for the expenditure

25 to fall within this exemption and if the process is

26 conducted in a manner substantially in accordance with the

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1 requirements of Sections 20-160, 25-60, 30-22, 50-5,

2 50-10, 50-10.5, 50-12, 50-13, 50-15, 50-20, 50-21, 50-35,

3 50-36, 50-37, 50-38, and 50-50 of this Code; however, for

4 Section 50-35, compliance applies only to contracts or

5 subcontracts over $100,000. Notice of each contract

6 entered into under this paragraph (18) that is related to

7 the procurement of goods and services identified in

8 paragraph (1) through (9) of this subsection shall be

9 published in the Procurement Bulletin within 14 calendar

10 days after contract execution. The Chief Procurement

11 Officer shall prescribe the form and content of the

12 notice. Each agency shall provide the Chief Procurement

13 Officer, on a monthly basis, in the form and content

14 prescribed by the Chief Procurement Officer, a report of

15 contracts that are related to the procurement of goods and

16 services identified in this subsection. At a minimum, this

17 report shall include the name of the contractor, a

18 description of the supply or service provided, the total

19 amount of the contract, the term of the contract, and the

20 exception to this Code utilized. A copy of any or all of

21 these contracts shall be made available to the Chief

22 Procurement Officer immediately upon request. The Chief

23 Procurement Officer shall submit a report to the Governor

24 and General Assembly no later than November 1 of each year

25 that includes, at a minimum, an annual summary of the

26 monthly information reported to the Chief Procurement

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1 Officer. This exemption becomes inoperative 5 years after

2 June 25, 2019 (the effective date of Public Act 101-27).

3 (19) Acquisition of modifications or adjustments,

4 limited to assistive technology devices and assistive

5 technology services, adaptive equipment, repairs, and

6 replacement parts to provide reasonable accommodations (i)

7 that enable a qualified applicant with a disability to

8 complete the job application process and be considered for

9 the position such qualified applicant desires, (ii) that

10 modify or adjust the work environment to enable a

11 qualified current employee with a disability to perform

12 the essential functions of the position held by that

13 employee, (iii) to enable a qualified current employee

14 with a disability to enjoy equal benefits and privileges

15 of employment as are enjoyed by other similarly situated

16 employees without disabilities, and (iv) that allow a

17 customer, client, claimant, or member of the public

18 seeking State services full use and enjoyment of and

19 access to its programs, services, or benefits.

20 For purposes of this paragraph (19):

21 "Assistive technology devices" means any item, piece

22 of equipment, or product system, whether acquired

23 commercially off the shelf, modified, or customized, that

24 is used to increase, maintain, or improve functional

25 capabilities of individuals with disabilities.

26 "Assistive technology services" means any service that

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1 directly assists an individual with a disability in

2 selection, acquisition, or use of an assistive technology

3 device.

4 "Qualified" has the same meaning and use as provided

5 under the federal Americans with Disabilities Act when

6 describing an individual with a disability.

7 (20) Procurement expenditures necessary for the

8 Illinois Commerce Commission to hire third-party

9 facilitators pursuant to Sections 16-105.17 and 16-108.18

10 of the Public Utilities Act or an ombudsman pursuant to

11 Section 16-107.5 of the Public Utilities Act, a

12 facilitator pursuant to Section 16-105.17 of the Public

13 Utilities Act, or a grid auditor pursuant to Section

14 16-105.10 of the Public Utilities Act.

15 (21) Procurement expenditures for the purchase,

16 renewal, and expansion of software, software licenses, or

17 software maintenance agreements that support the efforts

18 of the Illinois State Police to enforce, regulate, and

19 administer the Firearm Owners Identification Card Act, the

20 Firearm Concealed Carry Act, the Firearms Restraining

21 Order Act, the Firearm Dealer License Certification Act,

22 the Law Enforcement Agencies Data System (LEADS), the

23 Uniform Crime Reporting Act, the Criminal Identification

24 Act, the Illinois Uniform Conviction Information Act, and

25 the Gun Trafficking Information Act, or establish or

26 maintain record management systems necessary to conduct

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1 human trafficking investigations or gun trafficking or

2 other stolen firearm investigations. This paragraph (21)

3 applies to contracts entered into on or after January 10,

4 2023 (the effective date of Public Act 102-1116) and the

5 renewal of contracts that are in effect on January 10,

6 2023 (the effective date of Public Act 102-1116).

7 (22) Contracts for project management services and

8 system integration services required for the completion of

9 the State's enterprise resource planning project. This

10 exemption becomes inoperative 5 years after June 7, 2023

11 (the effective date of the changes made to this Section by

12 Public Act 103-8). This paragraph (22) applies to

13 contracts entered into on or after June 7, 2023 (the

14 effective date of the changes made to this Section by

15 Public Act 103-8) and the renewal of contracts that are in

16 effect on June 7, 2023 (the effective date of the changes

17 made to this Section by Public Act 103-8).

18 (23) Procurements necessary for the Department of

19 Insurance to implement the Illinois Health Benefits

20 Exchange Law if the Department of Insurance has made a

21 good faith determination that it is necessary and

22 appropriate for the expenditure to fall within this

23 exemption. The procurement process shall be conducted in a

24 manner substantially in accordance with the requirements

25 of Sections 20-160 and 25-60 and Article 50 of this Code. A

26 copy of these contracts shall be made available to the

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1 Chief Procurement Officer immediately upon request. This

2 paragraph is inoperative 5 years after June 27, 2023 (the

3 effective date of Public Act 103-103).

4 (24) Contracts for public education programming,

5 noncommercial sustaining announcements, public service

6 announcements, and public awareness and education

7 messaging with the nonprofit trade associations of the

8 providers of those services that inform the public on

9 immediate and ongoing health and safety risks and hazards.

10 (25) Procurements necessary for the Department of

11 Early Childhood to implement the Department of Early

12 Childhood Act if the Department has made a good faith

13 determination that it is necessary and appropriate for the

14 expenditure to fall within this exemption. This exemption

15 shall only be used for products and services procured

16 solely for use by the Department of Early Childhood. The

17 procurements may include those necessary to design and

18 build integrated, operational systems of programs and

19 services. The procurements may include, but are not

20 limited to, those necessary to align and update program

21 standards, integrate funding systems, design and establish

22 data and reporting systems, align and update models for

23 technical assistance and professional development, design

24 systems to manage grants and ensure compliance, design and

25 implement management and operational structures, and

26 establish new means of engaging with families, educators,

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1 providers, and stakeholders. The procurement processes

2 shall be conducted in a manner substantially in accordance

3 with the requirements of Article 50 (ethics) and Sections

4 5-5 (Procurement Policy Board), 5-7 (Commission on Equity

5 and Inclusion), 20-80 (contract files), 20-120

6 (subcontractors), 20-155 (paperwork), 20-160

7 (ethics/campaign contribution prohibitions), 25-60

8 (prevailing wage), and 25-90 (prohibited and authorized

9 cybersecurity) of this Code. Beginning January 1, 2025,

10 the Department of Early Childhood shall provide a

11 quarterly report to the General Assembly detailing a list

12 of expenditures and contracts for which the Department

13 uses this exemption. This paragraph is inoperative on and

14 after July 1, 2027.

15 (26) ~~(25)~~ Procurements that are necessary for

16 increasing the recruitment and retention of State

17 employees, particularly minority candidates for

18 employment, including:

19 (A) procurements related to registration fees for

20 job fairs and other outreach and recruitment events;

21 (B) production of recruitment materials; and

22 (C) other services related to recruitment and

23 retention of State employees.

24 The exemption under this paragraph (26) ~~(25)~~ applies

25 only if the State agency has made a good faith

26 determination that it is necessary and appropriate for the

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1 expenditure to fall within this paragraph (26) ~~(25)~~. The

2 procurement process under this paragraph (26) ~~(25)~~ shall

3 be conducted in a manner substantially in accordance with

4 the requirements of Sections 20-160 and 25-60 and Article

5 50 of this Code. A copy of these contracts shall be made

6 available to the Chief Procurement Officer immediately

7 upon request. Nothing in this paragraph (26) ~~(25)~~

8 authorizes the replacement or diminishment of State

9 responsibilities in hiring or the positions that

10 effectuate that hiring. This paragraph (26) ~~(25)~~ is

11 inoperative on and after June 30, 2029.

12 Notwithstanding any other provision of law, for contracts

13 with an annual value of more than $100,000 entered into on or

14 after October 1, 2017 under an exemption provided in any

15 paragraph of this subsection (b), except paragraph (1), (2),

16 or (5), each State agency shall post to the appropriate

17 procurement bulletin the name of the contractor, a description

18 of the supply or service provided, the total amount of the

19 contract, the term of the contract, and the exception to the

20 Code utilized. The chief procurement officer shall submit a

21 report to the Governor and General Assembly no later than

22 November 1 of each year that shall include, at a minimum, an

23 annual summary of the monthly information reported to the

24 chief procurement officer.

25 (c) This Code does not apply to the electric power

26 procurement process provided for under Section 1-75 of the

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1 Illinois Power Agency Act and Section 16-111.5 of the Public

2 Utilities Act. This Code does not apply to the procurement of

3 technical and policy experts pursuant to Section 1-129 of the

4 Illinois Power Agency Act.

5 (d) Except for Section 20-160 and Article 50 of this Code,

6 and as expressly required by Section 9.1 of the Illinois

7 Lottery Law, the provisions of this Code do not apply to the

8 procurement process provided for under Section 9.1 of the

9 Illinois Lottery Law.

10 (e) This Code does not apply to the process used by the

11 Capital Development Board to retain a person or entity to

12 assist the Capital Development Board with its duties related

13 to the determination of costs of a clean coal SNG brownfield

14 facility, as defined by Section 1-10 of the Illinois Power

15 Agency Act, as required in subsection (h-3) of Section 9-220

16 of the Public Utilities Act, including calculating the range

17 of capital costs, the range of operating and maintenance

18 costs, or the sequestration costs or monitoring the

19 construction of clean coal SNG brownfield facility for the

20 full duration of construction.

21 (f) (Blank).

22 (g) (Blank).

23 (h) This Code does not apply to the process to procure or

24 contracts entered into in accordance with Sections 11-5.2 and

25 11-5.3 of the Illinois Public Aid Code.

26 (i) Each chief procurement officer may access records

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1 necessary to review whether a contract, purchase, or other

2 expenditure is or is not subject to the provisions of this

3 Code, unless such records would be subject to attorney-client

4 privilege.

5 (j) This Code does not apply to the process used by the

6 Capital Development Board to retain an artist or work or works

7 of art as required in Section 14 of the Capital Development

8 Board Act.

9 (k) This Code does not apply to the process to procure

10 contracts, or contracts entered into, by the State Board of

11 Elections or the State Electoral Board for hearing officers

12 appointed pursuant to the Election Code.

13 (l) This Code does not apply to the processes used by the

14 Illinois Student Assistance Commission to procure supplies and

15 services paid for from the private funds of the Illinois

16 Prepaid Tuition Fund. As used in this subsection (l), "private

17 funds" means funds derived from deposits paid into the

18 Illinois Prepaid Tuition Trust Fund and the earnings thereon.

19 (m) This Code shall apply regardless of the source of

20 funds with which contracts are paid, including federal

21 assistance moneys. Except as specifically provided in this

22 Code, this Code shall not apply to procurement expenditures

23 necessary for the Department of Public Health to conduct the

24 Healthy Illinois Survey in accordance with Section 2310-431 of

25 the Department of Public Health Powers and Duties Law of the

26 Civil Administrative Code of Illinois.

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1 (Source: P.A. 102-175, eff. 7-29-21; 102-483, eff 1-1-22;

2 102-558, eff. 8-20-21; 102-600, eff. 8-27-21; 102-662, eff.

3 9-15-21; 102-721, eff. 1-1-23; 102-813, eff. 5-13-22;

4 102-1116, eff. 1-10-23; 103-8, eff. 6-7-23; 103-103, eff.

5 6-27-23; 103-570, eff. 1-1-24; 103-580, eff. 12-8-23; 103-594,

6 eff. 6-25-24; 103-605, eff. 7-1-24; 103-865, eff. 1-1-25;

7 revised 11-26-24.)

8 Section 15. The Illinois Public Aid Code is amended by

9 changing Section 5-5 as follows:

10 (305 ILCS 5/5-5)

11 (Text of Section before amendment by P.A. 103-808)

12 Sec. 5-5. Medical services. The Illinois Department, by

13 rule, shall determine the quantity and quality of and the rate

14 of reimbursement for the medical assistance for which payment

15 will be authorized, and the medical services to be provided,

16 which may include all or part of the following: (1) inpatient

17 hospital services; (2) outpatient hospital services; (3) other

18 laboratory and X-ray services; (4) skilled nursing home

19 services; (5) physicians' services whether furnished in the

20 office, the patient's home, a hospital, a skilled nursing

21 home, or elsewhere; (6) medical care, or any other type of

22 remedial care furnished by licensed practitioners; (7) home

23 health care services; (8) private duty nursing service; (9)

24 clinic services; (10) dental services, including prevention

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1 and treatment of periodontal disease and dental caries disease

2 for pregnant individuals, provided by an individual licensed

3 to practice dentistry or dental surgery; for purposes of this

4 item (10), "dental services" means diagnostic, preventive, or

5 corrective procedures provided by or under the supervision of

6 a dentist in the practice of his or her profession; (11)

7 physical therapy and related services; (12) prescribed drugs,

8 dentures, and prosthetic devices; and eyeglasses prescribed by

9 a physician skilled in the diseases of the eye, or by an

10 optometrist, whichever the person may select; (13) other

11 diagnostic, screening, preventive, and rehabilitative

12 services, including to ensure that the individual's need for

13 intervention or treatment of mental disorders or substance use

14 disorders or co-occurring mental health and substance use

15 disorders is determined using a uniform screening, assessment,

16 and evaluation process inclusive of criteria, for children and

17 adults; for purposes of this item (13), a uniform screening,

18 assessment, and evaluation process refers to a process that

19 includes an appropriate evaluation and, as warranted, a

20 referral; "uniform" does not mean the use of a singular

21 instrument, tool, or process that all must utilize; (14)

22 transportation and such other expenses as may be necessary;

23 (15) medical treatment of sexual assault survivors, as defined

24 in Section 1a of the Sexual Assault Survivors Emergency

25 Treatment Act, for injuries sustained as a result of the

26 sexual assault, including examinations and laboratory tests to

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1 discover evidence which may be used in criminal proceedings

2 arising from the sexual assault; (16) the diagnosis and

3 treatment of sickle cell anemia; (16.5) services performed by

4 a chiropractic physician licensed under the Medical Practice

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

6 including, but not limited to, chiropractic manipulative

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

8 of remedial care recognized under the laws of this State. The

9 term "any other type of remedial care" shall include nursing

10 care and nursing home service for persons who rely on

11 treatment by spiritual means alone through prayer for healing.

12 Notwithstanding any other provision of this Section, a

13 comprehensive tobacco use cessation program that includes

14 purchasing prescription drugs or prescription medical devices

15 approved by the Food and Drug Administration shall be covered

16 under the medical assistance program under this Article for

17 persons who are otherwise eligible for assistance under this

18 Article.

19 Notwithstanding any other provision of this Code,

20 reproductive health care that is otherwise legal in Illinois

21 shall be covered under the medical assistance program for

22 persons who are otherwise eligible for medical assistance

23 under this Article.

24 Notwithstanding any other provision of this Section, all

25 tobacco cessation medications approved by the United States

26 Food and Drug Administration and all individual and group

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1 tobacco cessation counseling services and telephone-based

2 counseling services and tobacco cessation medications provided

3 through the Illinois Tobacco Quitline shall be covered under

4 the medical assistance program for persons who are otherwise

5 eligible for assistance under this Article. The Department

6 shall comply with all federal requirements necessary to obtain

7 federal financial participation, as specified in 42 CFR

8 433.15(b)(7), for telephone-based counseling services provided

9 through the Illinois Tobacco Quitline, including, but not

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

11 interagency agreement with the Department of Public Health, as

12 administrator of the Illinois Tobacco Quitline; and (ii)

13 developing a cost allocation plan for Medicaid-allowable

14 Illinois Tobacco Quitline services in accordance with 45 CFR

15 95.507. The Department shall submit the memorandum of

16 understanding or interagency agreement, the cost allocation

17 plan, and all other necessary documentation to the Centers for

18 Medicare and Medicaid Services for review and approval.

19 Coverage under this paragraph shall be contingent upon federal

20 approval.

21 Notwithstanding any other provision of this Code, the

22 Illinois Department may not require, as a condition of payment

23 for any laboratory test authorized under this Article, that a

24 physician's handwritten signature appear on the laboratory

25 test order form. The Illinois Department may, however, impose

26 other appropriate requirements regarding laboratory test order

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1 documentation.

2 Upon receipt of federal approval of an amendment to the

3 Illinois Title XIX State Plan for this purpose, the Department

4 shall authorize the Chicago Public Schools (CPS) to procure a

5 vendor or vendors to manufacture eyeglasses for individuals

6 enrolled in a school within the CPS system. CPS shall ensure

7 that its vendor or vendors are enrolled as providers in the

8 medical assistance program and in any capitated Medicaid

9 managed care entity (MCE) serving individuals enrolled in a

10 school within the CPS system. Under any contract procured

11 under this provision, the vendor or vendors must serve only

12 individuals enrolled in a school within the CPS system. Claims

13 for services provided by CPS's vendor or vendors to recipients

14 of benefits in the medical assistance program under this Code,

15 the Children's Health Insurance Program, or the Covering ALL

16 KIDS Health Insurance Program shall be submitted to the

17 Department or the MCE in which the individual is enrolled for

18 payment and shall be reimbursed at the Department's or the

19 MCE's established rates or rate methodologies for eyeglasses.

20 On and after July 1, 2012, the Department of Healthcare

21 and Family Services may provide the following services to

22 persons eligible for assistance under this Article who are

23 participating in education, training or employment programs

24 operated by the Department of Human Services as successor to

25 the Department of Public Aid:

26 (1) dental services provided by or under the

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1 supervision of a dentist; and

2 (2) eyeglasses prescribed by a physician skilled in

3 the diseases of the eye, or by an optometrist, whichever

4 the person may select.

5 On and after July 1, 2018, the Department of Healthcare

6 and Family Services shall provide dental services to any adult

7 who is otherwise eligible for assistance under the medical

8 assistance program. As used in this paragraph, "dental

9 services" means diagnostic, preventative, restorative, or

10 corrective procedures, including procedures and services for

11 the prevention and treatment of periodontal disease and dental

12 caries disease, provided by an individual who is licensed to

13 practice dentistry or dental surgery or who is under the

14 supervision of a dentist in the practice of his or her

15 profession.

16 On and after July 1, 2018, targeted dental services, as

17 set forth in Exhibit D of the Consent Decree entered by the

18 United States District Court for the Northern District of

19 Illinois, Eastern Division, in the matter of Memisovski v.

20 Maram, Case No. 92 C 1982, that are provided to adults under

21 the medical assistance program shall be established at no less

22 than the rates set forth in the "New Rate" column in Exhibit D

23 of the Consent Decree for targeted dental services that are

24 provided to persons under the age of 18 under the medical

25 assistance program.

26 Subject to federal approval, on and after January 1, 2025,

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1 the rates paid for sedation evaluation and the provision of

2 deep sedation and intravenous sedation for the purpose of

3 dental services shall be increased by 33% above the rates in

4 effect on December 31, 2024. The rates paid for nitrous oxide

5 sedation shall not be impacted by this paragraph and shall

6 remain the same as the rates in effect on December 31, 2024.

7 Notwithstanding any other provision of this Code and

8 subject to federal approval, the Department may adopt rules to

9 allow a dentist who is volunteering his or her service at no

10 cost to render dental services through an enrolled

11 not-for-profit health clinic without the dentist personally

12 enrolling as a participating provider in the medical

13 assistance program. A not-for-profit health clinic shall

14 include a public health clinic or Federally Qualified Health

15 Center or other enrolled provider, as determined by the

16 Department, through which dental services covered under this

17 Section are performed. The Department shall establish a

18 process for payment of claims for reimbursement for covered

19 dental services rendered under this provision.

20 Subject to appropriation and to federal approval, the

21 Department shall file administrative rules updating the

22 Handicapping Labio-Lingual Deviation orthodontic scoring tool

23 by January 1, 2025, or as soon as practicable.

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

25 and Family Services shall administer and regulate a

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

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1 delivery of preventative dental services in a school setting

2 to children under 19 years of age. The Department shall

3 establish, by rule, guidelines for participation by providers

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

5 requirements established in the Dental Office Reference Manual

6 published by the Department that establishes the requirements

7 for dentists participating in the All Kids Dental School

8 Program. Every effort shall be made by the Department when

9 developing the program requirements to consider the different

10 geographic differences of both urban and rural areas of the

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

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

13 to participate in the school-based dental program administered

14 by the Department. Nothing in this paragraph shall be

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

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

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

18 the school-based dental program administered by the

19 Department.

20 The Illinois Department, by rule, may distinguish and

21 classify the medical services to be provided only in

22 accordance with the classes of persons designated in Section

23 5-2.

24 The Department of Healthcare and Family Services must

25 provide coverage and reimbursement for amino acid-based

26 elemental formulas, regardless of delivery method, for the

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1 diagnosis and treatment of (i) eosinophilic disorders and (ii)

2 short bowel syndrome when the prescribing physician has issued

3 a written order stating that the amino acid-based elemental

4 formula is medically necessary.

5 The Illinois Department shall authorize the provision of,

6 and shall authorize payment for, screening by low-dose

7 mammography for the presence of occult breast cancer for

8 individuals 35 years of age or older who are eligible for

9 medical assistance under this Article, as follows:

10 (A) A baseline mammogram for individuals 35 to 39

11 years of age.

12 (B) An annual mammogram for individuals 40 years of

13 age or older.

14 (C) A mammogram at the age and intervals considered

15 medically necessary by the individual's health care

16 provider for individuals under 40 years of age and having

17 a family history of breast cancer, prior personal history

18 of breast cancer, positive genetic testing, or other risk

19 factors.

20 (D) A comprehensive ultrasound screening and MRI of an

21 entire breast or breasts if a mammogram demonstrates

22 heterogeneous or dense breast tissue or when medically

23 necessary as determined by a physician licensed to

24 practice medicine in all of its branches.

25 (E) A screening MRI when medically necessary, as

26 determined by a physician licensed to practice medicine in

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1 all of its branches.

2 (F) A diagnostic mammogram when medically necessary,

3 as determined by a physician licensed to practice medicine

4 in all its branches, advanced practice registered nurse,

5 or physician assistant.

6 The Department shall not impose a deductible, coinsurance,

7 copayment, or any other cost-sharing requirement on the

8 coverage provided under this paragraph; except that this

9 sentence does not apply to coverage of diagnostic mammograms

10 to the extent such coverage would disqualify a high-deductible

11 health plan from eligibility for a health savings account

12 pursuant to Section 223 of the Internal Revenue Code (26

13 U.S.C. 223).

14 All screenings shall include a physical breast exam,

15 instruction on self-examination and information regarding the

16 frequency of self-examination and its value as a preventative

17 tool.

18 For purposes of this Section:

19 "Diagnostic mammogram" means a mammogram obtained using

20 diagnostic mammography.

21 "Diagnostic mammography" means a method of screening that

22 is designed to evaluate an abnormality in a breast, including

23 an abnormality seen or suspected on a screening mammogram or a

24 subjective or objective abnormality otherwise detected in the

25 breast.

26 "Low-dose mammography" means the x-ray examination of the

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1 breast using equipment dedicated specifically for mammography,

2 including the x-ray tube, filter, compression device, and

3 image receptor, with an average radiation exposure delivery of

4 less than one rad per breast for 2 views of an average size

5 breast. The term also includes digital mammography and

6 includes breast tomosynthesis.

7 "Breast tomosynthesis" means a radiologic procedure that

8 involves the acquisition of projection images over the

9 stationary breast to produce cross-sectional digital

10 three-dimensional images of the breast.

11 If, at any time, the Secretary of the United States

12 Department of Health and Human Services, or its successor

13 agency, promulgates rules or regulations to be published in

14 the Federal Register or publishes a comment in the Federal

15 Register or issues an opinion, guidance, or other action that

16 would require the State, pursuant to any provision of the

17 Patient Protection and Affordable Care Act (Public Law

18 111-148), including, but not limited to, 42 U.S.C.

19 18031(d)(3)(B) or any successor provision, to defray the cost

20 of any coverage for breast tomosynthesis outlined in this

21 paragraph, then the requirement that an insurer cover breast

22 tomosynthesis is inoperative other than any such coverage

23 authorized under Section 1902 of the Social Security Act, 42

24 U.S.C. 1396a, and the State shall not assume any obligation

25 for the cost of coverage for breast tomosynthesis set forth in

26 this paragraph.

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1 On and after January 1, 2016, the Department shall ensure

2 that all networks of care for adult clients of the Department

3 include access to at least one breast imaging Center of

4 Imaging Excellence as certified by the American College of

5 Radiology.

6 On and after January 1, 2012, providers participating in a

7 quality improvement program approved by the Department shall

8 be reimbursed for screening and diagnostic mammography at the

9 same rate as the Medicare program's rates, including the

10 increased reimbursement for digital mammography and, after

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

12 breast tomosynthesis.

13 The Department shall convene an expert panel including

14 representatives of hospitals, free-standing mammography

15 facilities, and doctors, including radiologists, to establish

16 quality standards for mammography.

17 On and after January 1, 2017, providers participating in a

18 breast cancer treatment quality improvement program approved

19 by the Department shall be reimbursed for breast cancer

20 treatment at a rate that is no lower than 95% of the Medicare

21 program's rates for the data elements included in the breast

22 cancer treatment quality program.

23 The Department shall convene an expert panel, including

24 representatives of hospitals, free-standing breast cancer

25 treatment centers, breast cancer quality organizations, and

26 doctors, including breast surgeons, reconstructive breast

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1 surgeons, oncologists, and primary care providers to establish

2 quality standards for breast cancer treatment.

3 Subject to federal approval, the Department shall

4 establish a rate methodology for mammography at federally

5 qualified health centers and other encounter-rate clinics.

6 These clinics or centers may also collaborate with other

7 hospital-based mammography facilities. By January 1, 2016, the

8 Department shall report to the General Assembly on the status

9 of the provision set forth in this paragraph.

10 The Department shall establish a methodology to remind

11 individuals who are age-appropriate for screening mammography,

12 but who have not received a mammogram within the previous 18

13 months, of the importance and benefit of screening

14 mammography. The Department shall work with experts in breast

15 cancer outreach and patient navigation to optimize these

16 reminders and shall establish a methodology for evaluating

17 their effectiveness and modifying the methodology based on the

18 evaluation.

19 The Department shall establish a performance goal for

20 primary care providers with respect to their female patients

21 over age 40 receiving an annual mammogram. This performance

22 goal shall be used to provide additional reimbursement in the

23 form of a quality performance bonus to primary care providers

24 who meet that goal.

25 The Department shall devise a means of case-managing or

26 patient navigation for beneficiaries diagnosed with breast

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1 cancer. This program shall initially operate as a pilot

2 program in areas of the State with the highest incidence of

3 mortality related to breast cancer. At least one pilot program

4 site shall be in the metropolitan Chicago area and at least one

5 site shall be outside the metropolitan Chicago area. On or

6 after July 1, 2016, the pilot program shall be expanded to

7 include one site in western Illinois, one site in southern

8 Illinois, one site in central Illinois, and 4 sites within

9 metropolitan Chicago. An evaluation of the pilot program shall

10 be carried out measuring health outcomes and cost of care for

11 those served by the pilot program compared to similarly

12 situated patients who are not served by the pilot program.

13 The Department shall require all networks of care to

14 develop a means either internally or by contract with experts

15 in navigation and community outreach to navigate cancer

16 patients to comprehensive care in a timely fashion. The

17 Department shall require all networks of care to include

18 access for patients diagnosed with cancer to at least one

19 academic commission on cancer-accredited cancer program as an

20 in-network covered benefit.

21 The Department shall provide coverage and reimbursement

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

23 marketing by the federal Food and Drug Administration for all

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

25 approval, the Department shall provide coverage and

26 reimbursement for a human papillomavirus (HPV) vaccine for

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

2 cervical dysplasia with a high risk of recurrence or

3 progression. The Department shall disallow any

4 preauthorization requirements for the administration of the

5 human papillomavirus (HPV) vaccine.

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

7 eligible for medical assistance under this Article shall

8 receive coverage for perinatal depression screenings for the

9 12-month period beginning on the last day of their pregnancy.

10 Medical assistance coverage under this paragraph shall be

11 conditioned on the use of a screening instrument approved by

12 the Department.

13 Any medical or health care provider shall immediately

14 recommend, to any pregnant individual who is being provided

15 prenatal services and is suspected of having a substance use

16 disorder as defined in the Substance Use Disorder Act,

17 referral to a local substance use disorder treatment program

18 licensed by the Department of Human Services or to a licensed

19 hospital which provides substance abuse treatment services.

20 The Department of Healthcare and Family Services shall assure

21 coverage for the cost of treatment of the drug abuse or

22 addiction for pregnant recipients in accordance with the

23 Illinois Medicaid Program in conjunction with the Department

24 of Human Services.

25 All medical providers providing medical assistance to

26 pregnant individuals under this Code shall receive information

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1 from the Department on the availability of services under any

2 program providing case management services for addicted

3 individuals, including information on appropriate referrals

4 for other social services that may be needed by addicted

5 individuals in addition to treatment for addiction.

6 The Illinois Department, in cooperation with the

7 Departments of Human Services (as successor to the Department

8 of Alcoholism and Substance Abuse) and Public Health, through

9 a public awareness campaign, may provide information

10 concerning treatment for alcoholism and drug abuse and

11 addiction, prenatal health care, and other pertinent programs

12 directed at reducing the number of drug-affected infants born

13 to recipients of medical assistance.

14 Neither the Department of Healthcare and Family Services

15 nor the Department of Human Services shall sanction the

16 recipient solely on the basis of the recipient's substance

17 abuse.

18 The Illinois Department shall establish such regulations

19 governing the dispensing of health services under this Article

20 as it shall deem appropriate. The Department should seek the

21 advice of formal professional advisory committees appointed by

22 the Director of the Illinois Department for the purpose of

23 providing regular advice on policy and administrative matters,

24 information dissemination and educational activities for

25 medical and health care providers, and consistency in

26 procedures to the Illinois Department.

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1 The Illinois Department may develop and contract with

2 Partnerships of medical providers to arrange medical services

3 for persons eligible under Section 5-2 of this Code.

4 Implementation of this Section may be by demonstration

5 projects in certain geographic areas. The Partnership shall be

6 represented by a sponsor organization. The Department, by

7 rule, shall develop qualifications for sponsors of

8 Partnerships. Nothing in this Section shall be construed to

9 require that the sponsor organization be a medical

10 organization.

11 The sponsor must negotiate formal written contracts with

12 medical providers for physician services, inpatient and

13 outpatient hospital care, home health services, treatment for

14 alcoholism and substance abuse, and other services determined

15 necessary by the Illinois Department by rule for delivery by

16 Partnerships. Physician services must include prenatal and

17 obstetrical care. The Illinois Department shall reimburse

18 medical services delivered by Partnership providers to clients

19 in target areas according to provisions of this Article and

20 the Illinois Health Finance Reform Act, except that:

21 (1) Physicians participating in a Partnership and

22 providing certain services, which shall be determined by

23 the Illinois Department, to persons in areas covered by

24 the Partnership may receive an additional surcharge for

25 such services.

26 (2) The Department may elect to consider and negotiate

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1 financial incentives to encourage the development of

2 Partnerships and the efficient delivery of medical care.

3 (3) Persons receiving medical services through

4 Partnerships may receive medical and case management

5 services above the level usually offered through the

6 medical assistance program.

7 Medical providers shall be required to meet certain

8 qualifications to participate in Partnerships to ensure the

9 delivery of high quality medical services. These

10 qualifications shall be determined by rule of the Illinois

11 Department and may be higher than qualifications for

12 participation in the medical assistance program. Partnership

13 sponsors may prescribe reasonable additional qualifications

14 for participation by medical providers, only with the prior

15 written approval of the Illinois Department.

16 Nothing in this Section shall limit the free choice of

17 practitioners, hospitals, and other providers of medical

18 services by clients. In order to ensure patient freedom of

19 choice, the Illinois Department shall immediately promulgate

20 all rules and take all other necessary actions so that

21 provided services may be accessed from therapeutically

22 certified optometrists to the full extent of the Illinois

23 Optometric Practice Act of 1987 without discriminating between

24 service providers.

25 The Department shall apply for a waiver from the United

26 States Health Care Financing Administration to allow for the

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1 implementation of Partnerships under this Section.

2 The Illinois Department shall require health care

3 providers to maintain records that document the medical care

4 and services provided to recipients of Medical Assistance

5 under this Article. Such records must be retained for a period

6 of not less than 6 years from the date of service or as

7 provided by applicable State law, whichever period is longer,

8 except that if an audit is initiated within the required

9 retention period then the records must be retained until the

10 audit is completed and every exception is resolved. The

11 Illinois Department shall require health care providers to

12 make available, when authorized by the patient, in writing,

13 the medical records in a timely fashion to other health care

14 providers who are treating or serving persons eligible for

15 Medical Assistance under this Article. All dispensers of

16 medical services shall be required to maintain and retain

17 business and professional records sufficient to fully and

18 accurately document the nature, scope, details and receipt of

19 the health care provided to persons eligible for medical

20 assistance under this Code, in accordance with regulations

21 promulgated by the Illinois Department. The rules and

22 regulations shall require that proof of the receipt of

23 prescription drugs, dentures, prosthetic devices and

24 eyeglasses by eligible persons under this Section accompany

25 each claim for reimbursement submitted by the dispenser of

26 such medical services. No such claims for reimbursement shall

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1 be approved for payment by the Illinois Department without

2 such proof of receipt, unless the Illinois Department shall

3 have put into effect and shall be operating a system of

4 post-payment audit and review which shall, on a sampling

5 basis, be deemed adequate by the Illinois Department to assure

6 that such drugs, dentures, prosthetic devices and eyeglasses

7 for which payment is being made are actually being received by

8 eligible recipients. Within 90 days after September 16, 1984

9 (the effective date of Public Act 83-1439), the Illinois

10 Department shall establish a current list of acquisition costs

11 for all prosthetic devices and any other items recognized as

12 medical equipment and supplies reimbursable under this Article

13 and shall update such list on a quarterly basis, except that

14 the acquisition costs of all prescription drugs shall be

15 updated no less frequently than every 30 days as required by

16 Section 5-5.12.

17 Notwithstanding any other law to the contrary, the

18 Illinois Department shall, within 365 days after July 22, 2013

19 (the effective date of Public Act 98-104), establish

20 procedures to permit skilled care facilities licensed under

21 the Nursing Home Care Act to submit monthly billing claims for

22 reimbursement purposes. Following development of these

23 procedures, the Department shall, by July 1, 2016, test the

24 viability of the new system and implement any necessary

25 operational or structural changes to its information

26 technology platforms in order to allow for the direct

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1 acceptance and payment of nursing home claims.

2 Notwithstanding any other law to the contrary, the

3 Illinois Department shall, within 365 days after August 15,

4 2014 (the effective date of Public Act 98-963), establish

5 procedures to permit ID/DD facilities licensed under the ID/DD

6 Community Care Act and MC/DD facilities licensed under the

7 MC/DD Act to submit monthly billing claims for reimbursement

8 purposes. Following development of these procedures, the

9 Department shall have an additional 365 days to test the

10 viability of the new system and to ensure that any necessary

11 operational or structural changes to its information

12 technology platforms are implemented.

13 The Illinois Department shall require all dispensers of

14 medical services, other than an individual practitioner or

15 group of practitioners, desiring to participate in the Medical

16 Assistance program established under this Article to disclose

17 all financial, beneficial, ownership, equity, surety or other

18 interests in any and all firms, corporations, partnerships,

19 associations, business enterprises, joint ventures, agencies,

20 institutions or other legal entities providing any form of

21 health care services in this State under this Article.

22 The Illinois Department may require that all dispensers of

23 medical services desiring to participate in the medical

24 assistance program established under this Article disclose,

25 under such terms and conditions as the Illinois Department may

26 by rule establish, all inquiries from clients and attorneys

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1 regarding medical bills paid by the Illinois Department, which

2 inquiries could indicate potential existence of claims or

3 liens for the Illinois Department.

4 Enrollment of a vendor shall be subject to a provisional

5 period and shall be conditional for one year. During the

6 period of conditional enrollment, the Department may terminate

7 the vendor's eligibility to participate in, or may disenroll

8 the vendor from, the medical assistance program without cause.

9 Unless otherwise specified, such termination of eligibility or

10 disenrollment is not subject to the Department's hearing

11 process. However, a disenrolled vendor may reapply without

12 penalty.

13 The Department has the discretion to limit the conditional

14 enrollment period for vendors based upon the category of risk

15 of the vendor.

16 Prior to enrollment and during the conditional enrollment

17 period in the medical assistance program, all vendors shall be

18 subject to enhanced oversight, screening, and review based on

19 the risk of fraud, waste, and abuse that is posed by the

20 category of risk of the vendor. The Illinois Department shall

21 establish the procedures for oversight, screening, and review,

22 which may include, but need not be limited to: criminal and

23 financial background checks; fingerprinting; license,

24 certification, and authorization verifications; unscheduled or

25 unannounced site visits; database checks; prepayment audit

26 reviews; audits; payment caps; payment suspensions; and other

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1 screening as required by federal or State law.

2 The Department shall define or specify the following: (i)

3 by provider notice, the "category of risk of the vendor" for

4 each type of vendor, which shall take into account the level of

5 screening applicable to a particular category of vendor under

6 federal law and regulations; (ii) by rule or provider notice,

7 the maximum length of the conditional enrollment period for

8 each category of risk of the vendor; and (iii) by rule, the

9 hearing rights, if any, afforded to a vendor in each category

10 of risk of the vendor that is terminated or disenrolled during

11 the conditional enrollment period.

12 To be eligible for payment consideration, a vendor's

13 payment claim or bill, either as an initial claim or as a

14 resubmitted claim following prior rejection, must be received

15 by the Illinois Department, or its fiscal intermediary, no

16 later than 180 days after the latest date on the claim on which

17 medical goods or services were provided, with the following

18 exceptions:

19 (1) In the case of a provider whose enrollment is in

20 process by the Illinois Department, the 180-day period

21 shall not begin until the date on the written notice from

22 the Illinois Department that the provider enrollment is

23 complete.

24 (2) In the case of errors attributable to the Illinois

25 Department or any of its claims processing intermediaries

26 which result in an inability to receive, process, or

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1 adjudicate a claim, the 180-day period shall not begin

2 until the provider has been notified of the error.

3 (3) In the case of a provider for whom the Illinois

4 Department initiates the monthly billing process.

5 (4) In the case of a provider operated by a unit of

6 local government with a population exceeding 3,000,000

7 when local government funds finance federal participation

8 for claims payments.

9 For claims for services rendered during a period for which

10 a recipient received retroactive eligibility, claims must be

11 filed within 180 days after the Department determines the

12 applicant is eligible. For claims for which the Illinois

13 Department is not the primary payer, claims must be submitted

14 to the Illinois Department within 180 days after the final

15 adjudication by the primary payer.

16 In the case of long term care facilities, within 120

17 calendar days of receipt by the facility of required

18 prescreening information, new admissions with associated

19 admission documents shall be submitted through the Medical

20 Electronic Data Interchange (MEDI) or the Recipient

21 Eligibility Verification (REV) System or shall be submitted

22 directly to the Department of Human Services using required

23 admission forms. Effective September 1, 2014, admission

24 documents, including all prescreening information, must be

25 submitted through MEDI or REV. Confirmation numbers assigned

26 to an accepted transaction shall be retained by a facility to

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1 verify timely submittal. Once an admission transaction has

2 been completed, all resubmitted claims following prior

3 rejection are subject to receipt no later than 180 days after

4 the admission transaction has been completed.

5 Claims that are not submitted and received in compliance

6 with the foregoing requirements shall not be eligible for

7 payment under the medical assistance program, and the State

8 shall have no liability for payment of those claims.

9 To the extent consistent with applicable information and

10 privacy, security, and disclosure laws, State and federal

11 agencies and departments shall provide the Illinois Department

12 access to confidential and other information and data

13 necessary to perform eligibility and payment verifications and

14 other Illinois Department functions. This includes, but is not

15 limited to: information pertaining to licensure;

16 certification; earnings; immigration status; citizenship; wage

17 reporting; unearned and earned income; pension income;

18 employment; supplemental security income; social security

19 numbers; National Provider Identifier (NPI) numbers; the

20 National Practitioner Data Bank (NPDB); program and agency

21 exclusions; taxpayer identification numbers; tax delinquency;

22 corporate information; and death records.

23 The Illinois Department shall enter into agreements with

24 State agencies and departments, and is authorized to enter

25 into agreements with federal agencies and departments, under

26 which such agencies and departments shall share data necessary

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1 for medical assistance program integrity functions and

2 oversight. The Illinois Department shall develop, in

3 cooperation with other State departments and agencies, and in

4 compliance with applicable federal laws and regulations,

5 appropriate and effective methods to share such data. At a

6 minimum, and to the extent necessary to provide data sharing,

7 the Illinois Department shall enter into agreements with State

8 agencies and departments, and is authorized to enter into

9 agreements with federal agencies and departments, including,

10 but not limited to: the Secretary of State; the Department of

11 Revenue; the Department of Public Health; the Department of

12 Human Services; and the Department of Financial and

13 Professional Regulation.

14 Beginning in fiscal year 2013, the Illinois Department

15 shall set forth a request for information to identify the

16 benefits of a pre-payment, post-adjudication, and post-edit

17 claims system with the goals of streamlining claims processing

18 and provider reimbursement, reducing the number of pending or

19 rejected claims, and helping to ensure a more transparent

20 adjudication process through the utilization of: (i) provider

21 data verification and provider screening technology; and (ii)

22 clinical code editing; and (iii) pre-pay, pre-adjudicated, or

23 post-adjudicated predictive modeling with an integrated case

24 management system with link analysis. Such a request for

25 information shall not be considered as a request for proposal

26 or as an obligation on the part of the Illinois Department to

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1 take any action or acquire any products or services.

2 The Illinois Department shall establish policies,

3 procedures, standards and criteria by rule for the

4 acquisition, repair and replacement of orthotic and prosthetic

5 devices and durable medical equipment. Such rules shall

6 provide, but not be limited to, the following services: (1)

7 immediate repair or replacement of such devices by recipients;

8 and (2) rental, lease, purchase or lease-purchase of durable

9 medical equipment in a cost-effective manner, taking into

10 consideration the recipient's medical prognosis, the extent of

11 the recipient's needs, and the requirements and costs for

12 maintaining such equipment. Subject to prior approval, such

13 rules shall enable a recipient to temporarily acquire and use

14 alternative or substitute devices or equipment pending repairs

15 or replacements of any device or equipment previously

16 authorized for such recipient by the Department.

17 Notwithstanding any provision of Section 5-5f to the contrary,

18 the Department may, by rule, exempt certain replacement

19 wheelchair parts from prior approval and, for wheelchairs,

20 wheelchair parts, wheelchair accessories, and related seating

21 and positioning items, determine the wholesale price by

22 methods other than actual acquisition costs.

23 The Department shall require, by rule, all providers of

24 durable medical equipment to be accredited by an accreditation

25 organization approved by the federal Centers for Medicare and

26 Medicaid Services and recognized by the Department in order to

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1 bill the Department for providing durable medical equipment to

2 recipients. No later than 15 months after the effective date

3 of the rule adopted pursuant to this paragraph, all providers

4 must meet the accreditation requirement.

5 In order to promote environmental responsibility, meet the

6 needs of recipients and enrollees, and achieve significant

7 cost savings, the Department, or a managed care organization

8 under contract with the Department, may provide recipients or

9 managed care enrollees who have a prescription or Certificate

10 of Medical Necessity access to refurbished durable medical

11 equipment under this Section (excluding prosthetic and

12 orthotic devices as defined in the Orthotics, Prosthetics, and

13 Pedorthics Practice Act and complex rehabilitation technology

14 products and associated services) through the State's

15 assistive technology program's reutilization program, using

16 staff with the Assistive Technology Professional (ATP)

17 Certification if the refurbished durable medical equipment:

18 (i) is available; (ii) is less expensive, including shipping

19 costs, than new durable medical equipment of the same type;

20 (iii) is able to withstand at least 3 years of use; (iv) is

21 cleaned, disinfected, sterilized, and safe in accordance with

22 federal Food and Drug Administration regulations and guidance

23 governing the reprocessing of medical devices in health care

24 settings; and (v) equally meets the needs of the recipient or

25 enrollee. The reutilization program shall confirm that the

26 recipient or enrollee is not already in receipt of the same or

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1 similar equipment from another service provider, and that the

2 refurbished durable medical equipment equally meets the needs

3 of the recipient or enrollee. Nothing in this paragraph shall

4 be construed to limit recipient or enrollee choice to obtain

5 new durable medical equipment or place any additional prior

6 authorization conditions on enrollees of managed care

7 organizations.

8 The Department shall execute, relative to the nursing home

9 prescreening project, written inter-agency agreements with the

10 Department of Human Services and the Department on Aging, to

11 effect the following: (i) intake procedures and common

12 eligibility criteria for those persons who are receiving

13 non-institutional services; and (ii) the establishment and

14 development of non-institutional services in areas of the

15 State where they are not currently available or are

16 undeveloped; and (iii) notwithstanding any other provision of

17 law, subject to federal approval, on and after July 1, 2012, an

18 increase in the determination of need (DON) scores from 29 to

19 37 for applicants for institutional and home and

20 community-based long term care; if and only if federal

21 approval is not granted, the Department may, in conjunction

22 with other affected agencies, implement utilization controls

23 or changes in benefit packages to effectuate a similar savings

24 amount for this population; and (iv) no later than July 1,

25 2013, minimum level of care eligibility criteria for

26 institutional and home and community-based long term care; and

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1 (v) no later than October 1, 2013, establish procedures to

2 permit long term care providers access to eligibility scores

3 for individuals with an admission date who are seeking or

4 receiving services from the long term care provider. In order

5 to select the minimum level of care eligibility criteria, the

6 Governor shall establish a workgroup that includes affected

7 agency representatives and stakeholders representing the

8 institutional and home and community-based long term care

9 interests. This Section shall not restrict the Department from

10 implementing lower level of care eligibility criteria for

11 community-based services in circumstances where federal

12 approval has been granted.

13 The Illinois Department shall develop and operate, in

14 cooperation with other State Departments and agencies and in

15 compliance with applicable federal laws and regulations,

16 appropriate and effective systems of health care evaluation

17 and programs for monitoring of utilization of health care

18 services and facilities, as it affects persons eligible for

19 medical assistance under this Code.

20 The Illinois Department shall report annually to the

21 General Assembly, no later than the second Friday in April of

22 1979 and each year thereafter, in regard to:

23 (a) actual statistics and trends in utilization of

24 medical services by public aid recipients;

25 (b) actual statistics and trends in the provision of

26 the various medical services by medical vendors;

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1 (c) current rate structures and proposed changes in

2 those rate structures for the various medical vendors; and

3 (d) efforts at utilization review and control by the

4 Illinois Department.

5 The period covered by each report shall be the 3 years

6 ending on the June 30 prior to the report. The report shall

7 include suggested legislation for consideration by the General

8 Assembly. The requirement for reporting to the General

9 Assembly shall be satisfied by filing copies of the report as

10 required by Section 3.1 of the General Assembly Organization

11 Act, and filing such additional copies with the State

12 Government Report Distribution Center for the General Assembly

13 as is required under paragraph (t) of Section 7 of the State

14 Library Act.

15 Rulemaking authority to implement Public Act 95-1045, if

16 any, is conditioned on the rules being adopted in accordance

17 with all provisions of the Illinois Administrative Procedure

18 Act and all rules and procedures of the Joint Committee on

19 Administrative Rules; any purported rule not so adopted, for

20 whatever reason, is unauthorized.

21 On and after July 1, 2012, the Department shall reduce any

22 rate of reimbursement for services or other payments or alter

23 any methodologies authorized by this Code to reduce any rate

24 of reimbursement for services or other payments in accordance

25 with Section 5-5e.

26 Because kidney transplantation can be an appropriate,

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1 cost-effective alternative to renal dialysis when medically

2 necessary and notwithstanding the provisions of Section 1-11

3 of this Code, beginning October 1, 2014, the Department shall

4 cover kidney transplantation for noncitizens with end-stage

5 renal disease who are not eligible for comprehensive medical

6 benefits, who meet the residency requirements of Section 5-3

7 of this Code, and who would otherwise meet the financial

8 requirements of the appropriate class of eligible persons

9 under Section 5-2 of this Code. To qualify for coverage of

10 kidney transplantation, such person must be receiving

11 emergency renal dialysis services covered by the Department.

12 Providers under this Section shall be prior approved and

13 certified by the Department to perform kidney transplantation

14 and the services under this Section shall be limited to

15 services associated with kidney transplantation.

16 Notwithstanding any other provision of this Code to the

17 contrary, on or after July 1, 2015, all FDA-approved ~~FDA~~

18 ~~approved~~ forms of medication assisted treatment prescribed for

19 the treatment of alcohol dependence or treatment of opioid

20 dependence shall be covered under both fee-for-service and

21 managed care medical assistance programs for persons who are

22 otherwise eligible for medical assistance under this Article

23 and shall not be subject to any (1) utilization control, other

24 than those established under the American Society of Addiction

25 Medicine patient placement criteria, (2) prior authorization

26 mandate, (3) lifetime restriction limit mandate, or (4)

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1 limitations on dosage.

2 On or after July 1, 2015, opioid antagonists prescribed

3 for the treatment of an opioid overdose, including the

4 medication product, administration devices, and any pharmacy

5 fees or hospital fees related to the dispensing, distribution,

6 and administration of the opioid antagonist, shall be covered

7 under the medical assistance program for persons who are

8 otherwise eligible for medical assistance under this Article.

9 As used in this Section, "opioid antagonist" means a drug that

10 binds to opioid receptors and blocks or inhibits the effect of

11 opioids acting on those receptors, including, but not limited

12 to, naloxone hydrochloride or any other similarly acting drug

13 approved by the U.S. Food and Drug Administration. The

14 Department shall not impose a copayment on the coverage

15 provided for naloxone hydrochloride under the medical

16 assistance program.

17 Upon federal approval, the Department shall provide

18 coverage and reimbursement for all drugs that are approved for

19 marketing by the federal Food and Drug Administration and that

20 are recommended by the federal Public Health Service or the

21 United States Centers for Disease Control and Prevention for

22 pre-exposure prophylaxis and related pre-exposure prophylaxis

23 services, including, but not limited to, HIV and sexually

24 transmitted infection screening, treatment for sexually

25 transmitted infections, medical monitoring, assorted labs, and

26 counseling to reduce the likelihood of HIV infection among

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1 individuals who are not infected with HIV but who are at high

2 risk of HIV infection.

3 A federally qualified health center, as defined in Section

4 1905(l)(2)(B) of the federal Social Security Act, shall be

5 reimbursed by the Department in accordance with the federally

6 qualified health center's encounter rate for services provided

7 to medical assistance recipients that are performed by a

8 dental hygienist, as defined under the Illinois Dental

9 Practice Act, working under the general supervision of a

10 dentist and employed by a federally qualified health center.

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

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

13 approval of a State Plan amendment to expand coverage for

14 family planning services that includes presumptive eligibility

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

16 poverty level. Coverage under this Section shall be effective

17 beginning no later than December 1, 2022.

18 Subject to approval by the federal Centers for Medicare

19 and Medicaid Services of a Title XIX State Plan amendment

20 electing the Program of All-Inclusive Care for the Elderly

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

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

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

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

25 the Code of Federal Regulations, PACE program services shall

26 become a covered benefit of the medical assistance program,

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1 subject to criteria established in accordance with all

2 applicable laws.

3 Notwithstanding any other provision of this Code,

4 community-based pediatric palliative care from a trained

5 interdisciplinary team shall be covered under the medical

6 assistance program as provided in Section 15 of the Pediatric

7 Palliative Care Act.

8 Notwithstanding any other provision of this Code, within

9 12 months after June 2, 2022 (the effective date of Public Act

10 102-1037) and subject to federal approval, acupuncture

11 services performed by an acupuncturist licensed under the

12 Acupuncture Practice Act who is acting within the scope of his

13 or her license shall be covered under the medical assistance

14 program. The Department shall apply for any federal waiver or

15 State Plan amendment, if required, to implement this

16 paragraph. The Department may adopt any rules, including

17 standards and criteria, necessary to implement this paragraph.

18 Notwithstanding any other provision of this Code, the

19 medical assistance program shall, subject to federal approval,

20 reimburse hospitals for costs associated with a newborn

21 screening test for the presence of metachromatic

22 leukodystrophy, as required under the Newborn ~~Metabolic~~

23 Screening Act, at a rate not less than the fee charged by the

24 Department of Public Health. Notwithstanding any other

25 provision of this Code, the medical assistance program shall,

26 subject to appropriation and federal approval, also reimburse

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1 hospitals for costs associated with all newborn screening

2 tests added on and after August 9, 2024 (the effective date of

3 Public Act 103-909) ~~this amendatory Act of the 103rd General~~

4 ~~Assembly~~ to the Newborn ~~Metabolic~~ Screening Act and required

5 to be performed under that Act at a rate not less than the fee

6 charged by the Department of Public Health. The Department

7 shall seek federal approval before the implementation of the

8 newborn screening test fees by the Department of Public

9 Health.

10 Notwithstanding any other provision of this Code,

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

12 cognitive assessment and care planning services provided to a

13 person who experiences signs or symptoms of cognitive

14 impairment, as defined by the Diagnostic and Statistical

15 Manual of Mental Disorders, Fifth Edition, shall be covered

16 under the medical assistance program for persons who are

17 otherwise eligible for medical assistance under this Article.

18 Notwithstanding any other provision of this Code,

19 medically necessary reconstructive services that are intended

20 to restore physical appearance shall be covered under the

21 medical assistance program for persons who are otherwise

22 eligible for medical assistance under this Article. As used in

23 this paragraph, "reconstructive services" means treatments

24 performed on structures of the body damaged by trauma to

25 restore physical appearance.

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

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1 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article

2 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,

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

4 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.

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

6 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.

7 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;

8 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.

9 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,

10 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;

11 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised

12 10-10-24.)

13 (Text of Section after amendment by P.A. 103-808)

14 Sec. 5-5. Medical services. The Illinois Department, by

15 rule, shall determine the quantity and quality of and the rate

16 of reimbursement for the medical assistance for which payment

17 will be authorized, and the medical services to be provided,

18 which may include all or part of the following: (1) inpatient

19 hospital services; (2) outpatient hospital services; (3) other

20 laboratory and X-ray services; (4) skilled nursing home

21 services; (5) physicians' services whether furnished in the

22 office, the patient's home, a hospital, a skilled nursing

23 home, or elsewhere; (6) medical care, or any other type of

24 remedial care furnished by licensed practitioners; (7) home

25 health care services; (8) private duty nursing service; (9)

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1 clinic services; (10) dental services, including prevention

2 and treatment of periodontal disease and dental caries disease

3 for pregnant individuals, provided by an individual licensed

4 to practice dentistry or dental surgery; for purposes of this

5 item (10), "dental services" means diagnostic, preventive, or

6 corrective procedures provided by or under the supervision of

7 a dentist in the practice of his or her profession; (11)

8 physical therapy and related services; (12) prescribed drugs,

9 dentures, and prosthetic devices; and eyeglasses prescribed by

10 a physician skilled in the diseases of the eye, or by an

11 optometrist, whichever the person may select; (13) other

12 diagnostic, screening, preventive, and rehabilitative

13 services, including to ensure that the individual's need for

14 intervention or treatment of mental disorders or substance use

15 disorders or co-occurring mental health and substance use

16 disorders is determined using a uniform screening, assessment,

17 and evaluation process inclusive of criteria, for children and

18 adults; for purposes of this item (13), a uniform screening,

19 assessment, and evaluation process refers to a process that

20 includes an appropriate evaluation and, as warranted, a

21 referral; "uniform" does not mean the use of a singular

22 instrument, tool, or process that all must utilize; (14)

23 transportation and such other expenses as may be necessary;

24 (15) medical treatment of sexual assault survivors, as defined

25 in Section 1a of the Sexual Assault Survivors Emergency

26 Treatment Act, for injuries sustained as a result of the

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1 sexual assault, including examinations and laboratory tests to

2 discover evidence which may be used in criminal proceedings

3 arising from the sexual assault; (16) the diagnosis and

4 treatment of sickle cell anemia; (16.5) services performed by

5 a chiropractic physician licensed under the Medical Practice

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

7 including, but not limited to, chiropractic manipulative

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

9 of remedial care recognized under the laws of this State. The

10 term "any other type of remedial care" shall include nursing

11 care and nursing home service for persons who rely on

12 treatment by spiritual means alone through prayer for healing.

13 Notwithstanding any other provision of this Section, a

14 comprehensive tobacco use cessation program that includes

15 purchasing prescription drugs or prescription medical devices

16 approved by the Food and Drug Administration shall be covered

17 under the medical assistance program under this Article for

18 persons who are otherwise eligible for assistance under this

19 Article.

20 Notwithstanding any other provision of this Code,

21 reproductive health care that is otherwise legal in Illinois

22 shall be covered under the medical assistance program for

23 persons who are otherwise eligible for medical assistance

24 under this Article.

25 Notwithstanding any other provision of this Section, all

26 tobacco cessation medications approved by the United States

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1 Food and Drug Administration and all individual and group

2 tobacco cessation counseling services and telephone-based

3 counseling services and tobacco cessation medications provided

4 through the Illinois Tobacco Quitline shall be covered under

5 the medical assistance program for persons who are otherwise

6 eligible for assistance under this Article. The Department

7 shall comply with all federal requirements necessary to obtain

8 federal financial participation, as specified in 42 CFR

9 433.15(b)(7), for telephone-based counseling services provided

10 through the Illinois Tobacco Quitline, including, but not

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

12 interagency agreement with the Department of Public Health, as

13 administrator of the Illinois Tobacco Quitline; and (ii)

14 developing a cost allocation plan for Medicaid-allowable

15 Illinois Tobacco Quitline services in accordance with 45 CFR

16 95.507. The Department shall submit the memorandum of

17 understanding or interagency agreement, the cost allocation

18 plan, and all other necessary documentation to the Centers for

19 Medicare and Medicaid Services for review and approval.

20 Coverage under this paragraph shall be contingent upon federal

21 approval.

22 Notwithstanding any other provision of this Code, the

23 Illinois Department may not require, as a condition of payment

24 for any laboratory test authorized under this Article, that a

25 physician's handwritten signature appear on the laboratory

26 test order form. The Illinois Department may, however, impose

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1 other appropriate requirements regarding laboratory test order

2 documentation.

3 Upon receipt of federal approval of an amendment to the

4 Illinois Title XIX State Plan for this purpose, the Department

5 shall authorize the Chicago Public Schools (CPS) to procure a

6 vendor or vendors to manufacture eyeglasses for individuals

7 enrolled in a school within the CPS system. CPS shall ensure

8 that its vendor or vendors are enrolled as providers in the

9 medical assistance program and in any capitated Medicaid

10 managed care entity (MCE) serving individuals enrolled in a

11 school within the CPS system. Under any contract procured

12 under this provision, the vendor or vendors must serve only

13 individuals enrolled in a school within the CPS system. Claims

14 for services provided by CPS's vendor or vendors to recipients

15 of benefits in the medical assistance program under this Code,

16 the Children's Health Insurance Program, or the Covering ALL

17 KIDS Health Insurance Program shall be submitted to the

18 Department or the MCE in which the individual is enrolled for

19 payment and shall be reimbursed at the Department's or the

20 MCE's established rates or rate methodologies for eyeglasses.

21 On and after July 1, 2012, the Department of Healthcare

22 and Family Services may provide the following services to

23 persons eligible for assistance under this Article who are

24 participating in education, training or employment programs

25 operated by the Department of Human Services as successor to

26 the Department of Public Aid:

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1 (1) dental services provided by or under the

2 supervision of a dentist; and

3 (2) eyeglasses prescribed by a physician skilled in

4 the diseases of the eye, or by an optometrist, whichever

5 the person may select.

6 On and after July 1, 2018, the Department of Healthcare

7 and Family Services shall provide dental services to any adult

8 who is otherwise eligible for assistance under the medical

9 assistance program. As used in this paragraph, "dental

10 services" means diagnostic, preventative, restorative, or

11 corrective procedures, including procedures and services for

12 the prevention and treatment of periodontal disease and dental

13 caries disease, provided by an individual who is licensed to

14 practice dentistry or dental surgery or who is under the

15 supervision of a dentist in the practice of his or her

16 profession.

17 On and after July 1, 2018, targeted dental services, as

18 set forth in Exhibit D of the Consent Decree entered by the

19 United States District Court for the Northern District of

20 Illinois, Eastern Division, in the matter of Memisovski v.

21 Maram, Case No. 92 C 1982, that are provided to adults under

22 the medical assistance program shall be established at no less

23 than the rates set forth in the "New Rate" column in Exhibit D

24 of the Consent Decree for targeted dental services that are

25 provided to persons under the age of 18 under the medical

26 assistance program.

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1 Subject to federal approval, on and after January 1, 2025,

2 the rates paid for sedation evaluation and the provision of

3 deep sedation and intravenous sedation for the purpose of

4 dental services shall be increased by 33% above the rates in

5 effect on December 31, 2024. The rates paid for nitrous oxide

6 sedation shall not be impacted by this paragraph and shall

7 remain the same as the rates in effect on December 31, 2024.

8 Notwithstanding any other provision of this Code and

9 subject to federal approval, the Department may adopt rules to

10 allow a dentist who is volunteering his or her service at no

11 cost to render dental services through an enrolled

12 not-for-profit health clinic without the dentist personally

13 enrolling as a participating provider in the medical

14 assistance program. A not-for-profit health clinic shall

15 include a public health clinic or Federally Qualified Health

16 Center or other enrolled provider, as determined by the

17 Department, through which dental services covered under this

18 Section are performed. The Department shall establish a

19 process for payment of claims for reimbursement for covered

20 dental services rendered under this provision.

21 Subject to appropriation and to federal approval, the

22 Department shall file administrative rules updating the

23 Handicapping Labio-Lingual Deviation orthodontic scoring tool

24 by January 1, 2025, or as soon as practicable.

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

26 and Family Services shall administer and regulate a

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

2 delivery of preventative dental services in a school setting

3 to children under 19 years of age. The Department shall

4 establish, by rule, guidelines for participation by providers

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

6 requirements established in the Dental Office Reference Manual

7 published by the Department that establishes the requirements

8 for dentists participating in the All Kids Dental School

9 Program. Every effort shall be made by the Department when

10 developing the program requirements to consider the different

11 geographic differences of both urban and rural areas of the

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

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

14 to participate in the school-based dental program administered

15 by the Department. Nothing in this paragraph shall be

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

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

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

19 the school-based dental program administered by the

20 Department.

21 The Illinois Department, by rule, may distinguish and

22 classify the medical services to be provided only in

23 accordance with the classes of persons designated in Section

24 5-2.

25 The Department of Healthcare and Family Services must

26 provide coverage and reimbursement for amino acid-based

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1 elemental formulas, regardless of delivery method, for the

2 diagnosis and treatment of (i) eosinophilic disorders and (ii)

3 short bowel syndrome when the prescribing physician has issued

4 a written order stating that the amino acid-based elemental

5 formula is medically necessary.

6 The Illinois Department shall authorize the provision of,

7 and shall authorize payment for, screening by low-dose

8 mammography for the presence of occult breast cancer for

9 individuals 35 years of age or older who are eligible for

10 medical assistance under this Article, as follows:

11 (A) A baseline mammogram for individuals 35 to 39

12 years of age.

13 (B) An annual mammogram for individuals 40 years of

14 age or older.

15 (C) A mammogram at the age and intervals considered

16 medically necessary by the individual's health care

17 provider for individuals under 40 years of age and having

18 a family history of breast cancer, prior personal history

19 of breast cancer, positive genetic testing, or other risk

20 factors.

21 (D) A comprehensive ultrasound screening and MRI of an

22 entire breast or breasts if a mammogram demonstrates

23 heterogeneous or dense breast tissue or when medically

24 necessary as determined by a physician licensed to

25 practice medicine in all of its branches.

26 (E) A screening MRI when medically necessary, as

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1 determined by a physician licensed to practice medicine in

2 all of its branches.

3 (F) A diagnostic mammogram when medically necessary,

4 as determined by a physician licensed to practice medicine

5 in all its branches, advanced practice registered nurse,

6 or physician assistant.

7 (G) Molecular breast imaging (MBI) 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

11 practice medicine in all of its branches, advanced

12 practice registered nurse, or physician assistant.

13 The Department shall not impose a deductible, coinsurance,

14 copayment, or any other cost-sharing requirement on the

15 coverage provided under this paragraph; except that this

16 sentence does not apply to coverage of diagnostic mammograms

17 to the extent such coverage would disqualify a high-deductible

18 health plan from eligibility for a health savings account

19 pursuant to Section 223 of the Internal Revenue Code (26

20 U.S.C. 223).

21 All screenings shall include a physical breast exam,

22 instruction on self-examination and information regarding the

23 frequency of self-examination and its value as a preventative

24 tool.

25 For purposes of this Section:

26 "Diagnostic mammogram" means a mammogram obtained using

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1 diagnostic mammography.

2 "Diagnostic mammography" means a method of screening that

3 is designed to evaluate an abnormality in a breast, including

4 an abnormality seen or suspected on a screening mammogram or a

5 subjective or objective abnormality otherwise detected in the

6 breast.

7 "Low-dose mammography" means the x-ray examination of the

8 breast using equipment dedicated specifically for mammography,

9 including the x-ray tube, filter, compression device, and

10 image receptor, with an average radiation exposure delivery of

11 less than one rad per breast for 2 views of an average size

12 breast. The term also includes digital mammography and

13 includes breast tomosynthesis.

14 "Breast tomosynthesis" means a radiologic procedure that

15 involves the acquisition of projection images over the

16 stationary breast to produce cross-sectional digital

17 three-dimensional images of the breast.

18 If, at any time, the Secretary of the United States

19 Department of Health and Human Services, or its successor

20 agency, promulgates rules or regulations to be published in

21 the Federal Register or publishes a comment in the Federal

22 Register or issues an opinion, guidance, or other action that

23 would require the State, pursuant to any provision of the

24 Patient Protection and Affordable Care Act (Public Law

25 111-148), including, but not limited to, 42 U.S.C.

26 18031(d)(3)(B) or any successor provision, to defray the cost

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1 of any coverage for breast tomosynthesis outlined in this

2 paragraph, then the requirement that an insurer cover breast

3 tomosynthesis is inoperative other than any such coverage

4 authorized under Section 1902 of the Social Security Act, 42

5 U.S.C. 1396a, and the State shall not assume any obligation

6 for the cost of coverage for breast tomosynthesis set forth in

7 this paragraph.

8 On and after January 1, 2016, the Department shall ensure

9 that all networks of care for adult clients of the Department

10 include access to at least one breast imaging Center of

11 Imaging Excellence as certified by the American College of

12 Radiology.

13 On and after January 1, 2012, providers participating in a

14 quality improvement program approved by the Department shall

15 be reimbursed for screening and diagnostic mammography at the

16 same rate as the Medicare program's rates, including the

17 increased reimbursement for digital mammography and, after

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

19 breast tomosynthesis.

20 The Department shall convene an expert panel including

21 representatives of hospitals, free-standing mammography

22 facilities, and doctors, including radiologists, to establish

23 quality standards for mammography.

24 On and after January 1, 2017, providers participating in a

25 breast cancer treatment quality improvement program approved

26 by the Department shall be reimbursed for breast cancer

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1 treatment at a rate that is no lower than 95% of the Medicare

2 program's rates for the data elements included in the breast

3 cancer treatment quality program.

4 The Department shall convene an expert panel, including

5 representatives of hospitals, free-standing breast cancer

6 treatment centers, breast cancer quality organizations, and

7 doctors, including radiologists that are trained in all forms

8 of FDA-approved ~~FDA approved~~ breast imaging technologies,

9 breast surgeons, reconstructive breast surgeons, oncologists,

10 and primary care providers to establish quality standards for

11 breast cancer treatment.

12 Subject to federal approval, the Department shall

13 establish a rate methodology for mammography at federally

14 qualified health centers and other encounter-rate clinics.

15 These clinics or centers may also collaborate with other

16 hospital-based mammography facilities. By January 1, 2016, the

17 Department shall report to the General Assembly on the status

18 of the provision set forth in this paragraph.

19 The Department shall establish a methodology to remind

20 individuals who are age-appropriate for screening mammography,

21 but who have not received a mammogram within the previous 18

22 months, of the importance and benefit of screening

23 mammography. The Department shall work with experts in breast

24 cancer outreach and patient navigation to optimize these

25 reminders and shall establish a methodology for evaluating

26 their effectiveness and modifying the methodology based on the

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1 evaluation.

2 The Department shall establish a performance goal for

3 primary care providers with respect to their female patients

4 over age 40 receiving an annual mammogram. This performance

5 goal shall be used to provide additional reimbursement in the

6 form of a quality performance bonus to primary care providers

7 who meet that goal.

8 The Department shall devise a means of case-managing or

9 patient navigation for beneficiaries diagnosed with breast

10 cancer. This program shall initially operate as a pilot

11 program in areas of the State with the highest incidence of

12 mortality related to breast cancer. At least one pilot program

13 site shall be in the metropolitan Chicago area and at least one

14 site shall be outside the metropolitan Chicago area. On or

15 after July 1, 2016, the pilot program shall be expanded to

16 include one site in western Illinois, one site in southern

17 Illinois, one site in central Illinois, and 4 sites within

18 metropolitan Chicago. An evaluation of the pilot program shall

19 be carried out measuring health outcomes and cost of care for

20 those served by the pilot program compared to similarly

21 situated patients who are not served by the pilot program.

22 The Department shall require all networks of care to

23 develop a means either internally or by contract with experts

24 in navigation and community outreach to navigate cancer

25 patients to comprehensive care in a timely fashion. The

26 Department shall require all networks of care to include

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1 access for patients diagnosed with cancer to at least one

2 academic commission on cancer-accredited cancer program as an

3 in-network covered benefit.

4 The Department shall provide coverage and reimbursement

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

6 marketing by the federal Food and Drug Administration for all

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

8 approval, the Department shall provide coverage and

9 reimbursement for a human papillomavirus (HPV) vaccine for

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

11 cervical dysplasia with a high risk of recurrence or

12 progression. The Department shall disallow any

13 preauthorization requirements for the administration of the

14 human papillomavirus (HPV) vaccine.

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

16 eligible for medical assistance under this Article shall

17 receive coverage for perinatal depression screenings for the

18 12-month period beginning on the last day of their pregnancy.

19 Medical assistance coverage under this paragraph shall be

20 conditioned on the use of a screening instrument approved by

21 the Department.

22 Any medical or health care provider shall immediately

23 recommend, to any pregnant individual who is being provided

24 prenatal services and is suspected of having a substance use

25 disorder as defined in the Substance Use Disorder Act,

26 referral to a local substance use disorder treatment program

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1 licensed by the Department of Human Services or to a licensed

2 hospital which provides substance abuse treatment services.

3 The Department of Healthcare and Family Services shall assure

4 coverage for the cost of treatment of the drug abuse or

5 addiction for pregnant recipients in accordance with the

6 Illinois Medicaid Program in conjunction with the Department

7 of Human Services.

8 All medical providers providing medical assistance to

9 pregnant individuals under this Code shall receive information

10 from the Department on the availability of services under any

11 program providing case management services for addicted

12 individuals, including information on appropriate referrals

13 for other social services that may be needed by addicted

14 individuals in addition to treatment for addiction.

15 The Illinois Department, in cooperation with the

16 Departments of Human Services (as successor to the Department

17 of Alcoholism and Substance Abuse) and Public Health, through

18 a public awareness campaign, may provide information

19 concerning treatment for alcoholism and drug abuse and

20 addiction, prenatal health care, and other pertinent programs

21 directed at reducing the number of drug-affected infants born

22 to recipients of medical assistance.

23 Neither the Department of Healthcare and Family Services

24 nor the Department of Human Services shall sanction the

25 recipient solely on the basis of the recipient's substance

26 abuse.

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1 The Illinois Department shall establish such regulations

2 governing the dispensing of health services under this Article

3 as it shall deem appropriate. The Department should seek the

4 advice of formal professional advisory committees appointed by

5 the Director of the Illinois Department for the purpose of

6 providing regular advice on policy and administrative matters,

7 information dissemination and educational activities for

8 medical and health care providers, and consistency in

9 procedures to the Illinois Department.

10 The Illinois Department may develop and contract with

11 Partnerships of medical providers to arrange medical services

12 for persons eligible under Section 5-2 of this Code.

13 Implementation of this Section may be by demonstration

14 projects in certain geographic areas. The Partnership shall be

15 represented by a sponsor organization. The Department, by

16 rule, shall develop qualifications for sponsors of

17 Partnerships. Nothing in this Section shall be construed to

18 require that the sponsor organization be a medical

19 organization.

20 The sponsor must negotiate formal written contracts with

21 medical providers for physician services, inpatient and

22 outpatient hospital care, home health services, treatment for

23 alcoholism and substance abuse, and other services determined

24 necessary by the Illinois Department by rule for delivery by

25 Partnerships. Physician services must include prenatal and

26 obstetrical care. The Illinois Department shall reimburse

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1 medical services delivered by Partnership providers to clients

2 in target areas according to provisions of this Article and

3 the Illinois Health Finance Reform Act, except that:

4 (1) Physicians participating in a Partnership and

5 providing certain services, which shall be determined by

6 the Illinois Department, to persons in areas covered by

7 the Partnership may receive an additional surcharge for

8 such services.

9 (2) The Department may elect to consider and negotiate

10 financial incentives to encourage the development of

11 Partnerships and the efficient delivery of medical care.

12 (3) Persons receiving medical services through

13 Partnerships may receive medical and case management

14 services above the level usually offered through the

15 medical assistance program.

16 Medical providers shall be required to meet certain

17 qualifications to participate in Partnerships to ensure the

18 delivery of high quality medical services. These

19 qualifications shall be determined by rule of the Illinois

20 Department and may be higher than qualifications for

21 participation in the medical assistance program. Partnership

22 sponsors may prescribe reasonable additional qualifications

23 for participation by medical providers, only with the prior

24 written approval of the Illinois Department.

25 Nothing in this Section shall limit the free choice of

26 practitioners, hospitals, and other providers of medical

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1 services by clients. In order to ensure patient freedom of

2 choice, the Illinois Department shall immediately promulgate

3 all rules and take all other necessary actions so that

4 provided services may be accessed from therapeutically

5 certified optometrists to the full extent of the Illinois

6 Optometric Practice Act of 1987 without discriminating between

7 service providers.

8 The Department shall apply for a waiver from the United

9 States Health Care Financing Administration to allow for the

10 implementation of Partnerships under this Section.

11 The Illinois Department shall require health care

12 providers to maintain records that document the medical care

13 and services provided to recipients of Medical Assistance

14 under this Article. Such records must be retained for a period

15 of not less than 6 years from the date of service or as

16 provided by applicable State law, whichever period is longer,

17 except that if an audit is initiated within the required

18 retention period then the records must be retained until the

19 audit is completed and every exception is resolved. The

20 Illinois Department shall require health care providers to

21 make available, when authorized by the patient, in writing,

22 the medical records in a timely fashion to other health care

23 providers who are treating or serving persons eligible for

24 Medical Assistance under this Article. All dispensers of

25 medical services shall be required to maintain and retain

26 business and professional records sufficient to fully and

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1 accurately document the nature, scope, details and receipt of

2 the health care provided to persons eligible for medical

3 assistance under this Code, in accordance with regulations

4 promulgated by the Illinois Department. The rules and

5 regulations shall require that proof of the receipt of

6 prescription drugs, dentures, prosthetic devices and

7 eyeglasses by eligible persons under this Section accompany

8 each claim for reimbursement submitted by the dispenser of

9 such medical services. No such claims for reimbursement shall

10 be approved for payment by the Illinois Department without

11 such proof of receipt, unless the Illinois Department shall

12 have put into effect and shall be operating a system of

13 post-payment audit and review which shall, on a sampling

14 basis, be deemed adequate by the Illinois Department to assure

15 that such drugs, dentures, prosthetic devices and eyeglasses

16 for which payment is being made are actually being received by

17 eligible recipients. Within 90 days after September 16, 1984

18 (the effective date of Public Act 83-1439), the Illinois

19 Department shall establish a current list of acquisition costs

20 for all prosthetic devices and any other items recognized as

21 medical equipment and supplies reimbursable under this Article

22 and shall update such list on a quarterly basis, except that

23 the acquisition costs of all prescription drugs shall be

24 updated no less frequently than every 30 days as required by

25 Section 5-5.12.

26 Notwithstanding any other law to the contrary, the

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1 Illinois Department shall, within 365 days after July 22, 2013

2 (the effective date of Public Act 98-104), establish

3 procedures to permit skilled care facilities licensed under

4 the Nursing Home Care Act to submit monthly billing claims for

5 reimbursement purposes. Following development of these

6 procedures, the Department shall, by July 1, 2016, test the

7 viability of the new system and implement any necessary

8 operational or structural changes to its information

9 technology platforms in order to allow for the direct

10 acceptance and payment of nursing home claims.

11 Notwithstanding any other law to the contrary, the

12 Illinois Department shall, within 365 days after August 15,

13 2014 (the effective date of Public Act 98-963), establish

14 procedures to permit ID/DD facilities licensed under the ID/DD

15 Community Care Act and MC/DD facilities licensed under the

16 MC/DD Act to submit monthly billing claims for reimbursement

17 purposes. Following development of these procedures, the

18 Department shall have an additional 365 days to test the

19 viability of the new system and to ensure that any necessary

20 operational or structural changes to its information

21 technology platforms are implemented.

22 The Illinois Department shall require all dispensers of

23 medical services, other than an individual practitioner or

24 group of practitioners, desiring to participate in the Medical

25 Assistance program established under this Article to disclose

26 all financial, beneficial, ownership, equity, surety or other

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1 interests in any and all firms, corporations, partnerships,

2 associations, business enterprises, joint ventures, agencies,

3 institutions or other legal entities providing any form of

4 health care services in this State under this Article.

5 The Illinois Department may require that all dispensers of

6 medical services desiring to participate in the medical

7 assistance program established under this Article disclose,

8 under such terms and conditions as the Illinois Department may

9 by rule establish, all inquiries from clients and attorneys

10 regarding medical bills paid by the Illinois Department, which

11 inquiries could indicate potential existence of claims or

12 liens for the Illinois Department.

13 Enrollment of a vendor shall be subject to a provisional

14 period and shall be conditional for one year. During the

15 period of conditional enrollment, the Department may terminate

16 the vendor's eligibility to participate in, or may disenroll

17 the vendor from, the medical assistance program without cause.

18 Unless otherwise specified, such termination of eligibility or

19 disenrollment is not subject to the Department's hearing

20 process. However, a disenrolled vendor may reapply without

21 penalty.

22 The Department has the discretion to limit the conditional

23 enrollment period for vendors based upon the category of risk

24 of the vendor.

25 Prior to enrollment and during the conditional enrollment

26 period in the medical assistance program, all vendors shall be

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1 subject to enhanced oversight, screening, and review based on

2 the risk of fraud, waste, and abuse that is posed by the

3 category of risk of the vendor. The Illinois Department shall

4 establish the procedures for oversight, screening, and review,

5 which may include, but need not be limited to: criminal and

6 financial background checks; fingerprinting; license,

7 certification, and authorization verifications; unscheduled or

8 unannounced site visits; database checks; prepayment audit

9 reviews; audits; payment caps; payment suspensions; and other

10 screening as required by federal or State law.

11 The Department shall define or specify the following: (i)

12 by provider notice, the "category of risk of the vendor" for

13 each type of vendor, which shall take into account the level of

14 screening applicable to a particular category of vendor under

15 federal law and regulations; (ii) by rule or provider notice,

16 the maximum length of the conditional enrollment period for

17 each category of risk of the vendor; and (iii) by rule, the

18 hearing rights, if any, afforded to a vendor in each category

19 of risk of the vendor that is terminated or disenrolled during

20 the conditional enrollment period.

21 To be eligible for payment consideration, a vendor's

22 payment claim or bill, either as an initial claim or as a

23 resubmitted claim following prior rejection, must be received

24 by the Illinois Department, or its fiscal intermediary, no

25 later than 180 days after the latest date on the claim on which

26 medical goods or services were provided, with the following

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1 exceptions:

2 (1) In the case of a provider whose enrollment is in

3 process by the Illinois Department, the 180-day period

4 shall not begin until the date on the written notice from

5 the Illinois Department that the provider enrollment is

6 complete.

7 (2) In the case of errors attributable to the Illinois

8 Department or any of its claims processing intermediaries

9 which result in an inability to receive, process, or

10 adjudicate a claim, the 180-day period shall not begin

11 until the provider has been notified of the error.

12 (3) In the case of a provider for whom the Illinois

13 Department initiates the monthly billing process.

14 (4) In the case of a provider operated by a unit of

15 local government with a population exceeding 3,000,000

16 when local government funds finance federal participation

17 for claims payments.

18 For claims for services rendered during a period for which

19 a recipient received retroactive eligibility, claims must be

20 filed within 180 days after the Department determines the

21 applicant is eligible. For claims for which the Illinois

22 Department is not the primary payer, claims must be submitted

23 to the Illinois Department within 180 days after the final

24 adjudication by the primary payer.

25 In the case of long term care facilities, within 120

26 calendar days of receipt by the facility of required

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1 prescreening information, new admissions with associated

2 admission documents shall be submitted through the Medical

3 Electronic Data Interchange (MEDI) or the Recipient

4 Eligibility Verification (REV) System or shall be submitted

5 directly to the Department of Human Services using required

6 admission forms. Effective September 1, 2014, admission

7 documents, including all prescreening information, must be

8 submitted through MEDI or REV. Confirmation numbers assigned

9 to an accepted transaction shall be retained by a facility to

10 verify timely submittal. Once an admission transaction has

11 been completed, all resubmitted claims following prior

12 rejection are subject to receipt no later than 180 days after

13 the admission transaction has been completed.

14 Claims that are not submitted and received in compliance

15 with the foregoing requirements shall not be eligible for

16 payment under the medical assistance program, and the State

17 shall have no liability for payment of those claims.

18 To the extent consistent with applicable information and

19 privacy, security, and disclosure laws, State and federal

20 agencies and departments shall provide the Illinois Department

21 access to confidential and other information and data

22 necessary to perform eligibility and payment verifications and

23 other Illinois Department functions. This includes, but is not

24 limited to: information pertaining to licensure;

25 certification; earnings; immigration status; citizenship; wage

26 reporting; unearned and earned income; pension income;

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1 employment; supplemental security income; social security

2 numbers; National Provider Identifier (NPI) numbers; the

3 National Practitioner Data Bank (NPDB); program and agency

4 exclusions; taxpayer identification numbers; tax delinquency;

5 corporate information; and death records.

6 The Illinois Department shall enter into agreements with

7 State agencies and departments, and is authorized to enter

8 into agreements with federal agencies and departments, under

9 which such agencies and departments shall share data necessary

10 for medical assistance program integrity functions and

11 oversight. The Illinois Department shall develop, in

12 cooperation with other State departments and agencies, and in

13 compliance with applicable federal laws and regulations,

14 appropriate and effective methods to share such data. At a

15 minimum, and to the extent necessary to provide data sharing,

16 the Illinois Department shall enter into agreements with State

17 agencies and departments, and is authorized to enter into

18 agreements with federal agencies and departments, including,

19 but not limited to: the Secretary of State; the Department of

20 Revenue; the Department of Public Health; the Department of

21 Human Services; and the Department of Financial and

22 Professional Regulation.

23 Beginning in fiscal year 2013, the Illinois Department

24 shall set forth a request for information to identify the

25 benefits of a pre-payment, post-adjudication, and post-edit

26 claims system with the goals of streamlining claims processing

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1 and provider reimbursement, reducing the number of pending or

2 rejected claims, and helping to ensure a more transparent

3 adjudication process through the utilization of: (i) provider

4 data verification and provider screening technology; and (ii)

5 clinical code editing; and (iii) pre-pay, pre-adjudicated, or

6 post-adjudicated predictive modeling with an integrated case

7 management system with link analysis. Such a request for

8 information shall not be considered as a request for proposal

9 or as an obligation on the part of the Illinois Department to

10 take any action or acquire any products or services.

11 The Illinois Department shall establish policies,

12 procedures, standards and criteria by rule for the

13 acquisition, repair and replacement of orthotic and prosthetic

14 devices and durable medical equipment. Such rules shall

15 provide, but not be limited to, the following services: (1)

16 immediate repair or replacement of such devices by recipients;

17 and (2) rental, lease, purchase or lease-purchase of durable

18 medical equipment in a cost-effective manner, taking into

19 consideration the recipient's medical prognosis, the extent of

20 the recipient's needs, and the requirements and costs for

21 maintaining such equipment. Subject to prior approval, such

22 rules shall enable a recipient to temporarily acquire and use

23 alternative or substitute devices or equipment pending repairs

24 or replacements of any device or equipment previously

25 authorized for such recipient by the Department.

26 Notwithstanding any provision of Section 5-5f to the contrary,

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1 the Department may, by rule, exempt certain replacement

2 wheelchair parts from prior approval and, for wheelchairs,

3 wheelchair parts, wheelchair accessories, and related seating

4 and positioning items, determine the wholesale price by

5 methods other than actual acquisition costs.

6 The Department shall require, by rule, all providers of

7 durable medical equipment to be accredited by an accreditation

8 organization approved by the federal Centers for Medicare and

9 Medicaid Services and recognized by the Department in order to

10 bill the Department for providing durable medical equipment to

11 recipients. No later than 15 months after the effective date

12 of the rule adopted pursuant to this paragraph, all providers

13 must meet the accreditation requirement.

14 In order to promote environmental responsibility, meet the

15 needs of recipients and enrollees, and achieve significant

16 cost savings, the Department, or a managed care organization

17 under contract with the Department, may provide recipients or

18 managed care enrollees who have a prescription or Certificate

19 of Medical Necessity access to refurbished durable medical

20 equipment under this Section (excluding prosthetic and

21 orthotic devices as defined in the Orthotics, Prosthetics, and

22 Pedorthics Practice Act and complex rehabilitation technology

23 products and associated services) through the State's

24 assistive technology program's reutilization program, using

25 staff with the Assistive Technology Professional (ATP)

26 Certification if the refurbished durable medical equipment:

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1 (i) is available; (ii) is less expensive, including shipping

2 costs, than new durable medical equipment of the same type;

3 (iii) is able to withstand at least 3 years of use; (iv) is

4 cleaned, disinfected, sterilized, and safe in accordance with

5 federal Food and Drug Administration regulations and guidance

6 governing the reprocessing of medical devices in health care

7 settings; and (v) equally meets the needs of the recipient or

8 enrollee. The reutilization program shall confirm that the

9 recipient or enrollee is not already in receipt of the same or

10 similar equipment from another service provider, and that the

11 refurbished durable medical equipment equally meets the needs

12 of the recipient or enrollee. Nothing in this paragraph shall

13 be construed to limit recipient or enrollee choice to obtain

14 new durable medical equipment or place any additional prior

15 authorization conditions on enrollees of managed care

16 organizations.

17 The Department shall execute, relative to the nursing home

18 prescreening project, written inter-agency agreements with the

19 Department of Human Services and the Department on Aging, to

20 effect the following: (i) intake procedures and common

21 eligibility criteria for those persons who are receiving

22 non-institutional services; and (ii) the establishment and

23 development of non-institutional services in areas of the

24 State where they are not currently available or are

25 undeveloped; and (iii) notwithstanding any other provision of

26 law, subject to federal approval, on and after July 1, 2012, an

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1 increase in the determination of need (DON) scores from 29 to

2 37 for applicants for institutional and home and

3 community-based long term care; if and only if federal

4 approval is not granted, the Department may, in conjunction

5 with other affected agencies, implement utilization controls

6 or changes in benefit packages to effectuate a similar savings

7 amount for this population; and (iv) no later than July 1,

8 2013, minimum level of care eligibility criteria for

9 institutional and home and community-based long term care; and

10 (v) no later than October 1, 2013, establish procedures to

11 permit long term care providers access to eligibility scores

12 for individuals with an admission date who are seeking or

13 receiving services from the long term care provider. In order

14 to select the minimum level of care eligibility criteria, the

15 Governor shall establish a workgroup that includes affected

16 agency representatives and stakeholders representing the

17 institutional and home and community-based long term care

18 interests. This Section shall not restrict the Department from

19 implementing lower level of care eligibility criteria for

20 community-based services in circumstances where federal

21 approval has been granted.

22 The Illinois Department shall develop and operate, in

23 cooperation with other State Departments and agencies and in

24 compliance with applicable federal laws and regulations,

25 appropriate and effective systems of health care evaluation

26 and programs for monitoring of utilization of health care

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1 services and facilities, as it affects persons eligible for

2 medical assistance under this Code.

3 The Illinois Department shall report annually to the

4 General Assembly, no later than the second Friday in April of

5 1979 and each year thereafter, in regard to:

6 (a) actual statistics and trends in utilization of

7 medical services by public aid recipients;

8 (b) actual statistics and trends in the provision of

9 the various medical services by medical vendors;

10 (c) current rate structures and proposed changes in

11 those rate structures for the various medical vendors; and

12 (d) efforts at utilization review and control by the

13 Illinois Department.

14 The period covered by each report shall be the 3 years

15 ending on the June 30 prior to the report. The report shall

16 include suggested legislation for consideration by the General

17 Assembly. The requirement for reporting to the General

18 Assembly shall be satisfied by filing copies of the report as

19 required by Section 3.1 of the General Assembly Organization

20 Act, and filing such additional copies with the State

21 Government Report Distribution Center for the General Assembly

22 as is required under paragraph (t) of Section 7 of the State

23 Library Act.

24 Rulemaking authority to implement Public Act 95-1045, if

25 any, is conditioned on the rules being adopted in accordance

26 with all provisions of the Illinois Administrative Procedure

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1 Act and all rules and procedures of the Joint Committee on

2 Administrative Rules; any purported rule not so adopted, for

3 whatever reason, is unauthorized.

4 On and after July 1, 2012, the Department shall reduce any

5 rate of reimbursement for services or other payments or alter

6 any methodologies authorized by this Code to reduce any rate

7 of reimbursement for services or other payments in accordance

8 with Section 5-5e.

9 Because kidney transplantation can be an appropriate,

10 cost-effective alternative to renal dialysis when medically

11 necessary and notwithstanding the provisions of Section 1-11

12 of this Code, beginning October 1, 2014, the Department shall

13 cover kidney transplantation for noncitizens with end-stage

14 renal disease who are not eligible for comprehensive medical

15 benefits, who meet the residency requirements of Section 5-3

16 of this Code, and who would otherwise meet the financial

17 requirements of the appropriate class of eligible persons

18 under Section 5-2 of this Code. To qualify for coverage of

19 kidney transplantation, such person must be receiving

20 emergency renal dialysis services covered by the Department.

21 Providers under this Section shall be prior approved and

22 certified by the Department to perform kidney transplantation

23 and the services under this Section shall be limited to

24 services associated with kidney transplantation.

25 Notwithstanding any other provision of this Code to the

26 contrary, on or after July 1, 2015, all FDA-approved ~~FDA~~

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1 ~~approved~~ forms of medication assisted treatment prescribed for

2 the treatment of alcohol dependence or treatment of opioid

3 dependence shall be covered under both fee-for-service and

4 managed care medical assistance programs for persons who are

5 otherwise eligible for medical assistance under this Article

6 and shall not be subject to any (1) utilization control, other

7 than those established under the American Society of Addiction

8 Medicine patient placement criteria, (2) prior authorization

9 mandate, (3) lifetime restriction limit mandate, or (4)

10 limitations on dosage.

11 On or after July 1, 2015, opioid antagonists prescribed

12 for the treatment of an opioid overdose, including the

13 medication product, administration devices, and any pharmacy

14 fees or hospital fees related to the dispensing, distribution,

15 and administration of the opioid antagonist, shall be covered

16 under the medical assistance program for persons who are

17 otherwise eligible for medical assistance under this Article.

18 As used in this Section, "opioid antagonist" means a drug that

19 binds to opioid receptors and blocks or inhibits the effect of

20 opioids acting on those receptors, including, but not limited

21 to, naloxone hydrochloride or any other similarly acting drug

22 approved by the U.S. Food and Drug Administration. The

23 Department shall not impose a copayment on the coverage

24 provided for naloxone hydrochloride under the medical

25 assistance program.

26 Upon federal approval, the Department shall provide

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1 coverage and reimbursement for all drugs that are approved for

2 marketing by the federal Food and Drug Administration and that

3 are recommended by the federal Public Health Service or the

4 United States Centers for Disease Control and Prevention for

5 pre-exposure prophylaxis and related pre-exposure prophylaxis

6 services, including, but not limited to, HIV and sexually

7 transmitted infection screening, treatment for sexually

8 transmitted infections, medical monitoring, assorted labs, and

9 counseling to reduce the likelihood of HIV infection among

10 individuals who are not infected with HIV but who are at high

11 risk of HIV infection.

12 A federally qualified health center, as defined in Section

13 1905(l)(2)(B) of the federal Social Security Act, shall be

14 reimbursed by the Department in accordance with the federally

15 qualified health center's encounter rate for services provided

16 to medical assistance recipients that are performed by a

17 dental hygienist, as defined under the Illinois Dental

18 Practice Act, working under the general supervision of a

19 dentist and employed by a federally qualified health center.

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

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

22 approval of a State Plan amendment to expand coverage for

23 family planning services that includes presumptive eligibility

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

25 poverty level. Coverage under this Section shall be effective

26 beginning no later than December 1, 2022.

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1 Subject to approval by the federal Centers for Medicare

2 and Medicaid Services of a Title XIX State Plan amendment

3 electing the Program of All-Inclusive Care for the Elderly

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

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

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

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

8 the Code of Federal Regulations, PACE program services shall

9 become a covered benefit of the medical assistance program,

10 subject to criteria established in accordance with all

11 applicable laws.

12 Notwithstanding any other provision of this Code,

13 community-based pediatric palliative care from a trained

14 interdisciplinary team shall be covered under the medical

15 assistance program as provided in Section 15 of the Pediatric

16 Palliative Care Act.

17 Notwithstanding any other provision of this Code, within

18 12 months after June 2, 2022 (the effective date of Public Act

19 102-1037) and subject to federal approval, acupuncture

20 services performed by an acupuncturist licensed under the

21 Acupuncture Practice Act who is acting within the scope of his

22 or her license shall be covered under the medical assistance

23 program. The Department shall apply for any federal waiver or

24 State Plan amendment, if required, to implement this

25 paragraph. The Department may adopt any rules, including

26 standards and criteria, necessary to implement this paragraph.

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1 Notwithstanding any other provision of this Code, the

2 medical assistance program shall, subject to federal approval,

3 reimburse hospitals for costs associated with a newborn

4 screening test for the presence of metachromatic

5 leukodystrophy, as required under the Newborn ~~Metabolic~~

6 Screening Act, at a rate not less than the fee charged by the

7 Department of Public Health. Notwithstanding any other

8 provision of this Code, the medical assistance program shall,

9 subject to appropriation and federal approval, also reimburse

10 hospitals for costs associated with all newborn screening

11 tests added on and after August 9, 2024 (the effective date of

12 Public Act 103-909) ~~this amendatory Act of the 103rd General~~

13 ~~Assembly~~ to the Newborn ~~Metabolic~~ Screening Act and required

14 to be performed under that Act at a rate not less than the fee

15 charged by the Department of Public Health. The Department

16 shall seek federal approval before the implementation of the

17 newborn screening test fees by the Department of Public

18 Health.

19 Notwithstanding any other provision of this Code,

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

21 cognitive assessment and care planning services provided to a

22 person who experiences signs or symptoms of cognitive

23 impairment, as defined by the Diagnostic and Statistical

24 Manual of Mental Disorders, Fifth Edition, shall be covered

25 under the medical assistance program for persons who are

26 otherwise eligible for medical assistance under this Article.

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1 Notwithstanding any other provision of this Code,

2 medically necessary reconstructive services that are intended

3 to restore physical appearance shall be covered under the

4 medical assistance program for persons who are otherwise

5 eligible for medical assistance under this Article. As used in

6 this paragraph, "reconstructive services" means treatments

7 performed on structures of the body damaged by trauma to

8 restore physical appearance.

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

10 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article

11 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,

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

13 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.

14 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;

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

16 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;

17 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.

18 1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,

19 Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;

20 103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.

21 8-9-24; revised 10-10-24.)

22 Section 20. The Newborn Metabolic Screening Act is amended

23 by changing the title of the Act and Sections 0.01 and 2 as

24 follows:

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1 (410 ILCS 240/Act title)

2 An Act concerning health ~~the disease of phenylketonuria~~

3 ~~and other metabolic diseases, designating certain powers and~~

4 ~~duties in relation thereto, providing penalties for violation~~

5 ~~thereof, to repeal an Act therein named and to make an~~

6 ~~appropriation in connection therewith~~.

7 (410 ILCS 240/0.01) (from Ch. 111 1/2, par. 4902.9)

8 Sec. 0.01. Short title. This Act may be cited as the

9 Newborn ~~Metabolic~~ Screening Act.

10 (Source: P.A. 95-695, eff. 11-5-07.)

11 (410 ILCS 240/2) (from Ch. 111 1/2, par. 4904)

12 Sec. 2. General provisions. The Department of Public

13 Health shall administer the provisions of this Act and shall:

14 (a) Institute and carry on an intensive educational

15 program among physicians, hospitals, public health nurses and

16 the public concerning disorders included in newborn screening.

17 This educational program shall include information about the

18 nature of the diseases and examinations for the detection of

19 the diseases in early infancy in order that measures may be

20 taken to prevent the disabilities resulting from the diseases.

21 (a-5) Require that all newborns be screened for the

22 presence of certain genetic, metabolic, and congenital

23 anomalies, including hearing disorders, as determined by the

24 Department, by rule.

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1 (a-5.1) Require that all blood and biological specimens

2 collected pursuant to this Act or the rules adopted under this

3 Act be submitted for testing to the nearest Department

4 laboratory designated to perform such tests. The following

5 provisions shall apply concerning testing:

6 (1) Beginning July 1, 2015, the base fee for newborn

7 screening services shall be $118. Beginning July 1, 2026,

8 the base fee for newborn screening services shall be $165.

9 The amount of 22% of the base fee must be allocated to the

10 Department for the Early Hearing Detection and

11 Intervention Program. The Department may develop a

12 reasonable fee structure and may levy additional fees

13 according to such structure to cover the cost of providing

14 these ~~this~~ testing services ~~service~~ and for the follow-up

15 of infants with an abnormal screening test; however,

16 additional fees may be levied no sooner than 6 months

17 prior to the beginning of testing for a new genetic,

18 metabolic, or congenital disorder. Fees collected from the

19 provision of this testing service shall be placed in the

20 Metabolic Screening and Treatment Fund. Other State and

21 federal funds for expenses related to metabolic, hearing,

22 or congenital disorder screening, follow-up, and treatment

23 programs may also be placed in the Fund.

24 (2) Moneys shall be appropriated from the Fund to the

25 Department solely for the purposes of providing newborn

26 screening, follow-up, and treatment programs. Nothing in

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1 this Act shall be construed to prohibit any licensed

2 medical facility from collecting additional specimens for

3 testing for metabolic or neonatal diseases or any other

4 diseases or conditions, as it deems fit. Any person

5 violating the provisions of this subsection (a-5.1) is

6 guilty of a petty offense.

7 (3) If the Department is unable to provide the

8 screening using the State Laboratory, it shall temporarily

9 provide such screening through an accredited laboratory

10 selected by the Department until the Department has the

11 capacity to provide screening through the State

12 Laboratory. If screening is provided on a temporary basis

13 through an accredited laboratory, the Department shall

14 substitute the fee charged by the accredited laboratory,

15 plus a 5% surcharge for documentation and handling, for

16 the fee authorized in this subsection (a-5.1). This

17 paragraph (3) does not apply to hearing screenings.

18 (a-5.2) Maintain a registry of cases, including

19 information of importance for the purpose of follow-up

20 services to assess long-term outcomes.

21 (a-5.3) Supply the necessary metabolic treatment formulas

22 where practicable for diagnosed cases of amino acid metabolism

23 disorders, including phenylketonuria, organic acid disorders,

24 and fatty acid oxidation disorders for as long as medically

25 indicated, when the product is not available through other

26 State agencies.

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1 (a-5.4) Arrange for or provide public health nursing,

2 nutrition, and social services and clinical consultation as

3 indicated.

4 (a-5.5) Utilize the Genetic and Metabolic Diseases

5 Advisory Committee established under the Genetic and Metabolic

6 Diseases Advisory Committee Act to provide guidance and

7 recommendations to the Department's newborn screening program.

8 The Genetic and Metabolic Diseases Advisory Committee shall

9 review the feasibility and advisability of including

10 additional metabolic, genetic, and congenital disorders in the

11 newborn screening panel, according to a review protocol

12 applied to each suggested addition to the screening panel. The

13 Department shall consider the recommendations of the Genetic

14 and Metabolic Diseases Advisory Committee in determining

15 whether to include an additional disorder in the screening

16 panel prior to proposing an administrative rule concerning

17 inclusion of an additional disorder in the newborn screening

18 panel. This subsection (a-5.5) does not apply to hearing

19 screenings. Notwithstanding any other provision of law, no new

20 screening may begin prior to the occurrence of all the

21 following:

22 (1) the establishment and verification of relevant and

23 appropriate performance specifications as defined under

24 the federal Clinical Laboratory Improvement Amendments and

25 regulations thereunder for U.S. Food and Drug

26 Administration-cleared or in-house developed methods,

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1 performed under an institutional review board-approved

2 protocol, if required;

3 (2) the availability of quality assurance testing

4 methodology for the processes set forth in item (1) of

5 this subsection (a-5.5);

6 (3) the acquisition and installment by the Department

7 of the equipment necessary to implement the screening

8 tests;

9 (4) the establishment of precise threshold values

10 ensuring defined disorder identification for each

11 screening test;

12 (5) the authentication of pilot testing achieving each

13 milestone described in items (1) through (4) of this

14 subsection (a-5.5) for each disorder screening test; and

15 (6) the authentication of achieving the potential of

16 high throughput standards for statewide volume of each

17 disorder screening test concomitant with each milestone

18 described in items (1) through (4) of this subsection

19 (a-5.5).

20 (a-6) (Blank).

21 (a-7) (Blank).

22 (a-8) (Blank).

23 (b) (Blank).

24 (c) (Blank).

25 (d) (Blank).

26 (e) (Blank).

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1 (Source: P.A. 98-440, eff. 8-16-13; 98-756, eff. 7-16-14;

2 99-403, eff. 8-19-15.)

3 Section 25. The Genetic Information Privacy Act is amended

4 by changing Section 30 as follows:

5 (410 ILCS 513/30)

6 Sec. 30. Disclosure of person tested and test results.

7 (a) No person may disclose or be compelled to disclose the

8 identity of any person upon whom a genetic test is performed or

9 the results of a genetic test in a manner that permits

10 identification of the subject of the test, except to the

11 following persons:

12 (1) The subject of the test or the subject's legally

13 authorized representative. This paragraph does not create

14 a duty or obligation under which a health care provider

15 must notify the subject's spouse or legal guardian of the

16 test results, and no such duty or obligation shall be

17 implied. No civil liability or criminal sanction under

18 this Act shall be imposed for any disclosure or

19 nondisclosure of a test result to a spouse by a physician

20 acting in good faith under this paragraph. For the purpose

21 of any proceedings, civil or criminal, the good faith of

22 any physician acting under this paragraph shall be

23 presumed.

24 (2) Any person designated in a specific written

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1 legally effective authorization for release of the test

2 results executed by the subject of the test or the

3 subject's legally authorized representative.

4 (3) An authorized agent or employee of a health

5 facility or health care provider if the health facility or

6 health care provider itself is authorized to obtain the

7 test results, the agent or employee provides patient care,

8 and the agent or employee has a need to know the

9 information in order to conduct the tests or provide care

10 or treatment.

11 (4) A health facility, health care provider, or health

12 care professional that procures, processes, distributes,

13 or uses:

14 (A) a human body part from a deceased person with

15 respect to medical information regarding that person;

16 or

17 (B) semen provided prior to the effective date of

18 this Act for the purpose of artificial insemination.

19 (5) Health facility staff committees for the purposes

20 of conducting program monitoring, program evaluation, or

21 service reviews.

22 (6) In the case of a minor under 18 years of age, the

23 health care provider, health care professional, or health

24 facility who ordered the test shall make a reasonable

25 effort to notify the minor's parent or legal guardian if,

26 in the professional judgment of the health care provider,

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1 health care professional, or health facility, notification

2 would be in the best interest of the minor and the health

3 care provider, health care professional, or health

4 facility has first sought unsuccessfully to persuade the

5 minor to notify the parent or legal guardian or after a

6 reasonable time after the minor has agreed to notify the

7 parent or legal guardian, the health care provider, health

8 care professional, or health facility has reason to

9 believe that the minor has not made the notification. This

10 paragraph shall not create a duty or obligation under

11 which a health care provider, health care professional, or

12 health facility must notify the minor's parent or legal

13 guardian of the test results, nor shall a duty or

14 obligation be implied. No civil liability or criminal

15 sanction under this Act shall be imposed for any

16 notification or non-notification of a minor's test result

17 by a health care provider, health care professional, or

18 health facility acting in good faith under this paragraph.

19 For the purpose of any proceeding, civil or criminal, the

20 good faith of any health care provider, health care

21 professional, or health facility acting under this

22 paragraph shall be presumed.

23 (b) All information and records held by a State agency,

24 local health authority, or health oversight agency pertaining

25 to genetic information shall be strictly confidential and

26 exempt from copying and inspection under the Freedom of

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1 Information Act. The information and records shall not be

2 released or made public by the State agency, local health

3 authority, or health oversight agency and shall not be

4 admissible as evidence nor discoverable in any action of any

5 kind in any court or before any tribunal, board, agency, or

6 person and shall be treated in the same manner as the

7 information and those records subject to the provisions of

8 Part 21 of Article VIII of the Code of Civil Procedure except

9 under the following circumstances:

10 (A) when made with the written consent of all

11 persons to whom the information pertains;

12 (B) when authorized by Section 5-4-3 of the

13 Unified Code of Corrections;

14 (C) when made for the sole purpose of implementing

15 the Newborn ~~Metabolic~~ Screening Act and rules; or

16 (D) when made under the authorization of the

17 Illinois Parentage Act of 2015.

18 Disclosure shall be limited to those who have a need to

19 know the information, and no additional disclosures may be

20 made.

21 (c) Disclosure by an insurer in accordance with the

22 requirements of the Article XL of the Illinois Insurance Code

23 shall be deemed compliance with this Section.

24 (Source: P.A. 98-1046, eff. 1-1-15; 99-85, eff. 1-1-16.)

25 Section 95. No acceleration or delay. Where this Act makes

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1 changes in a statute that is represented in this Act by text

2 that is not yet or no longer in effect (for example, a Section

3 represented by multiple versions), the use of that text does

4 not accelerate or delay the taking effect of (i) the changes

5 made by this Act or (ii) provisions derived from any other

6 Public Act.

7 Section 99. Effective date. This Act takes effect upon

8 becoming law.