Illinois General Assembly - Full Text of HB2050
Illinois General Assembly

  Bills & Resolutions  
  Compiled Statutes  
  Public Acts  
  Legislative Reports  
  IL Constitution  
  Legislative Guide  
  Legislative Glossary  

 Search By Number
 (example: HB0001)
Search Tips

Search By Keyword

Full Text of HB2050  103rd General Assembly




State of Illinois
2023 and 2024


Introduced 2/7/2023, by Rep. Dagmara Avelar


305 ILCS 5/5-5  from Ch. 23, par. 5-5
305 ILCS 5/5-5.06f new

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after July 1, 2023, medically necessary orthodontic services may be covered under the medical assistance program. Requires the Department of Healthcare and Family Services to use certain auto-qualifiers when determining whether an individual, who is otherwise eligible for medical assistance, is also eligible for coverage for a medically necessary orthodontic service. Provides that if the Department denies a claim for a medically necessary orthodontic service, the Department must, at a minimum, provide the following information to the provider of the orthodontic service: (i) the actual score of the orthodontic case; (ii) the name of the dentist or orthodontist who scored the orthodontic case; (iii) a detailed scoring sheet outlining the reasons for the score of the orthodontic case; and (iv) instructions on how to appeal the denied claim.

LRB103 03523 KTG 48529 b





HB2050LRB103 03523 KTG 48529 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 and by adding Section 5-5.06f as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    (Text of Section after amendment by P.A. 102-1018 and P.A.
9    Sec. 5-5. Medical services. The Illinois Department, by
10rule, shall determine the quantity and quality of and the rate
11of reimbursement for the medical assistance for which payment
12will be authorized, and the medical services to be provided,
13which may include all or part of the following: (1) inpatient
14hospital services; (2) outpatient hospital services; (3) other
15laboratory and X-ray services; (4) skilled nursing home
16services; (5) physicians' services whether furnished in the
17office, the patient's home, a hospital, a skilled nursing
18home, or elsewhere; (6) medical care, or any other type of
19remedial care furnished by licensed practitioners; (7) home
20health care services; (8) private duty nursing service; (9)
21clinic services; (10) dental services, including prevention
22and treatment of periodontal disease and dental caries disease
23for pregnant individuals, provided by an individual licensed



HB2050- 2 -LRB103 03523 KTG 48529 b

1to practice dentistry or dental surgery, and on and after July
21, 2023, medically necessary orthodontic services as provided
3in Section 5-5.06f; for purposes of this item (10), "dental
4services" means diagnostic, preventive, or corrective
5procedures provided by or under the supervision of a dentist
6in the practice of his or her profession; (11) physical
7therapy and related services; (12) prescribed drugs, dentures,
8and prosthetic devices; and eyeglasses prescribed by a
9physician skilled in the diseases of the eye, or by an
10optometrist, whichever the person may select; (13) other
11diagnostic, screening, preventive, and rehabilitative
12services, including to ensure that the individual's need for
13intervention or treatment of mental disorders or substance use
14disorders or co-occurring mental health and substance use
15disorders is determined using a uniform screening, assessment,
16and evaluation process inclusive of criteria, for children and
17adults; for purposes of this item (13), a uniform screening,
18assessment, and evaluation process refers to a process that
19includes an appropriate evaluation and, as warranted, a
20referral; "uniform" does not mean the use of a singular
21instrument, tool, or process that all must utilize; (14)
22transportation and such other expenses as may be necessary;
23(15) medical treatment of sexual assault survivors, as defined
24in Section 1a of the Sexual Assault Survivors Emergency
25Treatment Act, for injuries sustained as a result of the
26sexual assault, including examinations and laboratory tests to



HB2050- 3 -LRB103 03523 KTG 48529 b

1discover evidence which may be used in criminal proceedings
2arising from the sexual assault; (16) the diagnosis and
3treatment of sickle cell anemia; (16.5) services performed by
4a chiropractic physician licensed under the Medical Practice
5Act of 1987 and acting within the scope of his or her license,
6including, but not limited to, chiropractic manipulative
7treatment; and (17) any other medical care, and any other type
8of remedial care recognized under the laws of this State. The
9term "any other type of remedial care" shall include nursing
10care and nursing home service for persons who rely on
11treatment by spiritual means alone through prayer for healing.
12    Notwithstanding any other provision of this Section, a
13comprehensive tobacco use cessation program that includes
14purchasing prescription drugs or prescription medical devices
15approved by the Food and Drug Administration shall be covered
16under the medical assistance program under this Article for
17persons who are otherwise eligible for assistance under this
19    Notwithstanding any other provision of this Code,
20reproductive health care that is otherwise legal in Illinois
21shall be covered under the medical assistance program for
22persons who are otherwise eligible for medical assistance
23under this Article.
24    Notwithstanding any other provision of this Section, all
25tobacco cessation medications approved by the United States
26Food and Drug Administration and all individual and group



HB2050- 4 -LRB103 03523 KTG 48529 b

1tobacco cessation counseling services and telephone-based
2counseling services and tobacco cessation medications provided
3through the Illinois Tobacco Quitline shall be covered under
4the medical assistance program for persons who are otherwise
5eligible for assistance under this Article. The Department
6shall comply with all federal requirements necessary to obtain
7federal financial participation, as specified in 42 CFR
8433.15(b)(7), for telephone-based counseling services provided
9through the Illinois Tobacco Quitline, including, but not
10limited to: (i) entering into a memorandum of understanding or
11interagency agreement with the Department of Public Health, as
12administrator of the Illinois Tobacco Quitline; and (ii)
13developing a cost allocation plan for Medicaid-allowable
14Illinois Tobacco Quitline services in accordance with 45 CFR
1595.507. The Department shall submit the memorandum of
16understanding or interagency agreement, the cost allocation
17plan, and all other necessary documentation to the Centers for
18Medicare and Medicaid Services for review and approval.
19Coverage under this paragraph shall be contingent upon federal
21    Notwithstanding any other provision of this Code, the
22Illinois Department may not require, as a condition of payment
23for any laboratory test authorized under this Article, that a
24physician's handwritten signature appear on the laboratory
25test order form. The Illinois Department may, however, impose
26other appropriate requirements regarding laboratory test order



HB2050- 5 -LRB103 03523 KTG 48529 b

2    Upon receipt of federal approval of an amendment to the
3Illinois Title XIX State Plan for this purpose, the Department
4shall authorize the Chicago Public Schools (CPS) to procure a
5vendor or vendors to manufacture eyeglasses for individuals
6enrolled in a school within the CPS system. CPS shall ensure
7that its vendor or vendors are enrolled as providers in the
8medical assistance program and in any capitated Medicaid
9managed care entity (MCE) serving individuals enrolled in a
10school within the CPS system. Under any contract procured
11under this provision, the vendor or vendors must serve only
12individuals enrolled in a school within the CPS system. Claims
13for services provided by CPS's vendor or vendors to recipients
14of benefits in the medical assistance program under this Code,
15the Children's Health Insurance Program, or the Covering ALL
16KIDS Health Insurance Program shall be submitted to the
17Department or the MCE in which the individual is enrolled for
18payment and shall be reimbursed at the Department's or the
19MCE's established rates or rate methodologies for eyeglasses.
20    On and after July 1, 2012, the Department of Healthcare
21and Family Services may provide the following services to
22persons eligible for assistance under this Article who are
23participating in education, training or employment programs
24operated by the Department of Human Services as successor to
25the Department of Public Aid:
26        (1) dental services provided by or under the



HB2050- 6 -LRB103 03523 KTG 48529 b

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
6and Family Services shall provide dental services to any adult
7who is otherwise eligible for assistance under the medical
8assistance program. As used in this paragraph, "dental
9services" means diagnostic, preventative, restorative, or
10corrective procedures, including procedures and services for
11the prevention and treatment of periodontal disease and dental
12caries disease, provided by an individual who is licensed to
13practice dentistry or dental surgery or who is under the
14supervision of a dentist in the practice of his or her
16    On and after July 1, 2018, targeted dental services, as
17set forth in Exhibit D of the Consent Decree entered by the
18United States District Court for the Northern District of
19Illinois, Eastern Division, in the matter of Memisovski v.
20Maram, Case No. 92 C 1982, that are provided to adults under
21the medical assistance program shall be established at no less
22than the rates set forth in the "New Rate" column in Exhibit D
23of the Consent Decree for targeted dental services that are
24provided to persons under the age of 18 under the medical
25assistance program.
26    Notwithstanding any other provision of this Code and



HB2050- 7 -LRB103 03523 KTG 48529 b

1subject to federal approval, the Department may adopt rules to
2allow a dentist who is volunteering his or her service at no
3cost to render dental services through an enrolled
4not-for-profit health clinic without the dentist personally
5enrolling as a participating provider in the medical
6assistance program. A not-for-profit health clinic shall
7include a public health clinic or Federally Qualified Health
8Center or other enrolled provider, as determined by the
9Department, through which dental services covered under this
10Section are performed. The Department shall establish a
11process for payment of claims for reimbursement for covered
12dental services rendered under this provision.
13    On and after January 1, 2022, the Department of Healthcare
14and Family Services shall administer and regulate a
15school-based dental program that allows for the out-of-office
16delivery of preventative dental services in a school setting
17to children under 19 years of age. The Department shall
18establish, by rule, guidelines for participation by providers
19and set requirements for follow-up referral care based on the
20requirements established in the Dental Office Reference Manual
21published by the Department that establishes the requirements
22for dentists participating in the All Kids Dental School
23Program. Every effort shall be made by the Department when
24developing the program requirements to consider the different
25geographic differences of both urban and rural areas of the
26State for initial treatment and necessary follow-up care. No



HB2050- 8 -LRB103 03523 KTG 48529 b

1provider shall be charged a fee by any unit of local government
2to participate in the school-based dental program administered
3by the Department. Nothing in this paragraph shall be
4construed to limit or preempt a home rule unit's or school
5district's authority to establish, change, or administer a
6school-based dental program in addition to, or independent of,
7the school-based dental program administered by the
9    The Illinois Department, by rule, may distinguish and
10classify the medical services to be provided only in
11accordance with the classes of persons designated in Section
13    The Department of Healthcare and Family Services must
14provide coverage and reimbursement for amino acid-based
15elemental formulas, regardless of delivery method, for the
16diagnosis and treatment of (i) eosinophilic disorders and (ii)
17short bowel syndrome when the prescribing physician has issued
18a written order stating that the amino acid-based elemental
19formula is medically necessary.
20    The Illinois Department shall authorize the provision of,
21and shall authorize payment for, screening by low-dose
22mammography for the presence of occult breast cancer for
23individuals 35 years of age or older who are eligible for
24medical assistance under this Article, as follows:
25        (A) A baseline mammogram for individuals 35 to 39
26    years of age.



HB2050- 9 -LRB103 03523 KTG 48529 b

1        (B) An annual mammogram for individuals 40 years of
2    age or older.
3        (C) A mammogram at the age and intervals considered
4    medically necessary by the individual's health care
5    provider for individuals under 40 years of age and having
6    a family history of breast cancer, prior personal history
7    of breast cancer, positive genetic testing, or other risk
8    factors.
9        (D) A comprehensive ultrasound screening and MRI of an
10    entire breast or breasts if a mammogram demonstrates
11    heterogeneous or dense breast tissue or when medically
12    necessary as determined by a physician licensed to
13    practice medicine in all of its branches.
14        (E) A screening MRI when medically necessary, as
15    determined by a physician licensed to practice medicine in
16    all of its branches.
17        (F) A diagnostic mammogram when medically necessary,
18    as determined by a physician licensed to practice medicine
19    in all its branches, advanced practice registered nurse,
20    or physician assistant.
21    The Department shall not impose a deductible, coinsurance,
22copayment, or any other cost-sharing requirement on the
23coverage provided under this paragraph; except that this
24sentence does not apply to coverage of diagnostic mammograms
25to the extent such coverage would disqualify a high-deductible
26health plan from eligibility for a health savings account



HB2050- 10 -LRB103 03523 KTG 48529 b

1pursuant to Section 223 of the Internal Revenue Code (26
2U.S.C. 223).
3    All screenings shall include a physical breast exam,
4instruction on self-examination and information regarding the
5frequency of self-examination and its value as a preventative
7     For purposes of this Section:
8    "Diagnostic mammogram" means a mammogram obtained using
9diagnostic mammography.
10    "Diagnostic mammography" means a method of screening that
11is designed to evaluate an abnormality in a breast, including
12an abnormality seen or suspected on a screening mammogram or a
13subjective or objective abnormality otherwise detected in the
15    "Low-dose mammography" means the x-ray examination of the
16breast using equipment dedicated specifically for mammography,
17including the x-ray tube, filter, compression device, and
18image receptor, with an average radiation exposure delivery of
19less than one rad per breast for 2 views of an average size
20breast. The term also includes digital mammography and
21includes breast tomosynthesis.
22    "Breast tomosynthesis" means a radiologic procedure that
23involves the acquisition of projection images over the
24stationary breast to produce cross-sectional digital
25three-dimensional images of the breast.
26    If, at any time, the Secretary of the United States



HB2050- 11 -LRB103 03523 KTG 48529 b

1Department of Health and Human Services, or its successor
2agency, promulgates rules or regulations to be published in
3the Federal Register or publishes a comment in the Federal
4Register or issues an opinion, guidance, or other action that
5would require the State, pursuant to any provision of the
6Patient Protection and Affordable Care Act (Public Law
7111-148), including, but not limited to, 42 U.S.C.
818031(d)(3)(B) or any successor provision, to defray the cost
9of any coverage for breast tomosynthesis outlined in this
10paragraph, then the requirement that an insurer cover breast
11tomosynthesis is inoperative other than any such coverage
12authorized under Section 1902 of the Social Security Act, 42
13U.S.C. 1396a, and the State shall not assume any obligation
14for the cost of coverage for breast tomosynthesis set forth in
15this paragraph.
16    On and after January 1, 2016, the Department shall ensure
17that all networks of care for adult clients of the Department
18include access to at least one breast imaging Center of
19Imaging Excellence as certified by the American College of
21    On and after January 1, 2012, providers participating in a
22quality improvement program approved by the Department shall
23be reimbursed for screening and diagnostic mammography at the
24same rate as the Medicare program's rates, including the
25increased reimbursement for digital mammography and, after
26January 1, 2023 (the effective date of Public Act 102-1018)



HB2050- 12 -LRB103 03523 KTG 48529 b

1this amendatory Act of the 102nd General Assembly, breast
3    The Department shall convene an expert panel including
4representatives of hospitals, free-standing mammography
5facilities, and doctors, including radiologists, to establish
6quality standards for mammography.
7    On and after January 1, 2017, providers participating in a
8breast cancer treatment quality improvement program approved
9by the Department shall be reimbursed for breast cancer
10treatment at a rate that is no lower than 95% of the Medicare
11program's rates for the data elements included in the breast
12cancer treatment quality program.
13    The Department shall convene an expert panel, including
14representatives of hospitals, free-standing breast cancer
15treatment centers, breast cancer quality organizations, and
16doctors, including breast surgeons, reconstructive breast
17surgeons, oncologists, and primary care providers to establish
18quality standards for breast cancer treatment.
19    Subject to federal approval, the Department shall
20establish a rate methodology for mammography at federally
21qualified health centers and other encounter-rate clinics.
22These clinics or centers may also collaborate with other
23hospital-based mammography facilities. By January 1, 2016, the
24Department shall report to the General Assembly on the status
25of the provision set forth in this paragraph.
26    The Department shall establish a methodology to remind



HB2050- 13 -LRB103 03523 KTG 48529 b

1individuals who are age-appropriate for screening mammography,
2but who have not received a mammogram within the previous 18
3months, of the importance and benefit of screening
4mammography. The Department shall work with experts in breast
5cancer outreach and patient navigation to optimize these
6reminders and shall establish a methodology for evaluating
7their effectiveness and modifying the methodology based on the
9    The Department shall establish a performance goal for
10primary care providers with respect to their female patients
11over age 40 receiving an annual mammogram. This performance
12goal shall be used to provide additional reimbursement in the
13form of a quality performance bonus to primary care providers
14who meet that goal.
15    The Department shall devise a means of case-managing or
16patient navigation for beneficiaries diagnosed with breast
17cancer. This program shall initially operate as a pilot
18program in areas of the State with the highest incidence of
19mortality related to breast cancer. At least one pilot program
20site shall be in the metropolitan Chicago area and at least one
21site shall be outside the metropolitan Chicago area. On or
22after July 1, 2016, the pilot program shall be expanded to
23include one site in western Illinois, one site in southern
24Illinois, one site in central Illinois, and 4 sites within
25metropolitan Chicago. An evaluation of the pilot program shall
26be carried out measuring health outcomes and cost of care for



HB2050- 14 -LRB103 03523 KTG 48529 b

1those served by the pilot program compared to similarly
2situated patients who are not served by the pilot program.
3    The Department shall require all networks of care to
4develop a means either internally or by contract with experts
5in navigation and community outreach to navigate cancer
6patients to comprehensive care in a timely fashion. The
7Department shall require all networks of care to include
8access for patients diagnosed with cancer to at least one
9academic commission on cancer-accredited cancer program as an
10in-network covered benefit.
11    The Department shall provide coverage and reimbursement
12for a human papillomavirus (HPV) vaccine that is approved for
13marketing by the federal Food and Drug Administration for all
14persons between the ages of 9 and 45 and persons of the age of
1546 and above who have been diagnosed with cervical dysplasia
16with a high risk of recurrence or progression. The Department
17shall disallow any preauthorization requirements for the
18administration of the human papillomavirus (HPV) vaccine.
19    On or after July 1, 2022, individuals who are otherwise
20eligible for medical assistance under this Article shall
21receive coverage for perinatal depression screenings for the
2212-month period beginning on the last day of their pregnancy.
23Medical assistance coverage under this paragraph shall be
24conditioned on the use of a screening instrument approved by
25the Department.
26    Any medical or health care provider shall immediately



HB2050- 15 -LRB103 03523 KTG 48529 b

1recommend, to any pregnant individual who is being provided
2prenatal services and is suspected of having a substance use
3disorder as defined in the Substance Use Disorder Act,
4referral to a local substance use disorder treatment program
5licensed by the Department of Human Services or to a licensed
6hospital which provides substance abuse treatment services.
7The Department of Healthcare and Family Services shall assure
8coverage for the cost of treatment of the drug abuse or
9addiction for pregnant recipients in accordance with the
10Illinois Medicaid Program in conjunction with the Department
11of Human Services.
12    All medical providers providing medical assistance to
13pregnant individuals under this Code shall receive information
14from the Department on the availability of services under any
15program providing case management services for addicted
16individuals, including information on appropriate referrals
17for other social services that may be needed by addicted
18individuals in addition to treatment for addiction.
19    The Illinois Department, in cooperation with the
20Departments of Human Services (as successor to the Department
21of Alcoholism and Substance Abuse) and Public Health, through
22a public awareness campaign, may provide information
23concerning treatment for alcoholism and drug abuse and
24addiction, prenatal health care, and other pertinent programs
25directed at reducing the number of drug-affected infants born
26to recipients of medical assistance.



HB2050- 16 -LRB103 03523 KTG 48529 b

1    Neither the Department of Healthcare and Family Services
2nor the Department of Human Services shall sanction the
3recipient solely on the basis of the recipient's substance
5    The Illinois Department shall establish such regulations
6governing the dispensing of health services under this Article
7as it shall deem appropriate. The Department should seek the
8advice of formal professional advisory committees appointed by
9the Director of the Illinois Department for the purpose of
10providing regular advice on policy and administrative matters,
11information dissemination and educational activities for
12medical and health care providers, and consistency in
13procedures to the Illinois Department.
14    The Illinois Department may develop and contract with
15Partnerships of medical providers to arrange medical services
16for persons eligible under Section 5-2 of this Code.
17Implementation of this Section may be by demonstration
18projects in certain geographic areas. The Partnership shall be
19represented by a sponsor organization. The Department, by
20rule, shall develop qualifications for sponsors of
21Partnerships. Nothing in this Section shall be construed to
22require that the sponsor organization be a medical
24    The sponsor must negotiate formal written contracts with
25medical providers for physician services, inpatient and
26outpatient hospital care, home health services, treatment for



HB2050- 17 -LRB103 03523 KTG 48529 b

1alcoholism and substance abuse, and other services determined
2necessary by the Illinois Department by rule for delivery by
3Partnerships. Physician services must include prenatal and
4obstetrical care. The Illinois Department shall reimburse
5medical services delivered by Partnership providers to clients
6in target areas according to provisions of this Article and
7the Illinois Health Finance Reform Act, except that:
8        (1) Physicians participating in a Partnership and
9    providing certain services, which shall be determined by
10    the Illinois Department, to persons in areas covered by
11    the Partnership may receive an additional surcharge for
12    such services.
13        (2) The Department may elect to consider and negotiate
14    financial incentives to encourage the development of
15    Partnerships and the efficient delivery of medical care.
16        (3) Persons receiving medical services through
17    Partnerships may receive medical and case management
18    services above the level usually offered through the
19    medical assistance program.
20    Medical providers shall be required to meet certain
21qualifications to participate in Partnerships to ensure the
22delivery of high quality medical services. These
23qualifications shall be determined by rule of the Illinois
24Department and may be higher than qualifications for
25participation in the medical assistance program. Partnership
26sponsors may prescribe reasonable additional qualifications



HB2050- 18 -LRB103 03523 KTG 48529 b

1for participation by medical providers, only with the prior
2written approval of the Illinois Department.
3    Nothing in this Section shall limit the free choice of
4practitioners, hospitals, and other providers of medical
5services by clients. In order to ensure patient freedom of
6choice, the Illinois Department shall immediately promulgate
7all rules and take all other necessary actions so that
8provided services may be accessed from therapeutically
9certified optometrists to the full extent of the Illinois
10Optometric Practice Act of 1987 without discriminating between
11service providers.
12    The Department shall apply for a waiver from the United
13States Health Care Financing Administration to allow for the
14implementation of Partnerships under this Section.
15    The Illinois Department shall require health care
16providers to maintain records that document the medical care
17and services provided to recipients of Medical Assistance
18under this Article. Such records must be retained for a period
19of not less than 6 years from the date of service or as
20provided by applicable State law, whichever period is longer,
21except that if an audit is initiated within the required
22retention period then the records must be retained until the
23audit is completed and every exception is resolved. The
24Illinois Department shall require health care providers to
25make available, when authorized by the patient, in writing,
26the medical records in a timely fashion to other health care



HB2050- 19 -LRB103 03523 KTG 48529 b

1providers who are treating or serving persons eligible for
2Medical Assistance under this Article. All dispensers of
3medical services shall be required to maintain and retain
4business and professional records sufficient to fully and
5accurately document the nature, scope, details and receipt of
6the health care provided to persons eligible for medical
7assistance under this Code, in accordance with regulations
8promulgated by the Illinois Department. The rules and
9regulations shall require that proof of the receipt of
10prescription drugs, dentures, prosthetic devices and
11eyeglasses by eligible persons under this Section accompany
12each claim for reimbursement submitted by the dispenser of
13such medical services. No such claims for reimbursement shall
14be approved for payment by the Illinois Department without
15such proof of receipt, unless the Illinois Department shall
16have put into effect and shall be operating a system of
17post-payment audit and review which shall, on a sampling
18basis, be deemed adequate by the Illinois Department to assure
19that such drugs, dentures, prosthetic devices and eyeglasses
20for which payment is being made are actually being received by
21eligible recipients. Within 90 days after September 16, 1984
22(the effective date of Public Act 83-1439), the Illinois
23Department shall establish a current list of acquisition costs
24for all prosthetic devices and any other items recognized as
25medical equipment and supplies reimbursable under this Article
26and shall update such list on a quarterly basis, except that



HB2050- 20 -LRB103 03523 KTG 48529 b

1the acquisition costs of all prescription drugs shall be
2updated no less frequently than every 30 days as required by
3Section 5-5.12.
4    Notwithstanding any other law to the contrary, the
5Illinois Department shall, within 365 days after July 22, 2013
6(the effective date of Public Act 98-104), establish
7procedures to permit skilled care facilities licensed under
8the Nursing Home Care Act to submit monthly billing claims for
9reimbursement purposes. Following development of these
10procedures, the Department shall, by July 1, 2016, test the
11viability of the new system and implement any necessary
12operational or structural changes to its information
13technology platforms in order to allow for the direct
14acceptance and payment of nursing home claims.
15    Notwithstanding any other law to the contrary, the
16Illinois Department shall, within 365 days after August 15,
172014 (the effective date of Public Act 98-963), establish
18procedures to permit ID/DD facilities licensed under the ID/DD
19Community Care Act and MC/DD facilities licensed under the
20MC/DD Act to submit monthly billing claims for reimbursement
21purposes. Following development of these procedures, the
22Department shall have an additional 365 days to test the
23viability of the new system and to ensure that any necessary
24operational or structural changes to its information
25technology platforms are implemented.
26    The Illinois Department shall require all dispensers of



HB2050- 21 -LRB103 03523 KTG 48529 b

1medical services, other than an individual practitioner or
2group of practitioners, desiring to participate in the Medical
3Assistance program established under this Article to disclose
4all financial, beneficial, ownership, equity, surety or other
5interests in any and all firms, corporations, partnerships,
6associations, business enterprises, joint ventures, agencies,
7institutions or other legal entities providing any form of
8health care services in this State under this Article.
9    The Illinois Department may require that all dispensers of
10medical services desiring to participate in the medical
11assistance program established under this Article disclose,
12under such terms and conditions as the Illinois Department may
13by rule establish, all inquiries from clients and attorneys
14regarding medical bills paid by the Illinois Department, which
15inquiries could indicate potential existence of claims or
16liens for the Illinois Department.
17    Enrollment of a vendor shall be subject to a provisional
18period and shall be conditional for one year. During the
19period of conditional enrollment, the Department may terminate
20the vendor's eligibility to participate in, or may disenroll
21the vendor from, the medical assistance program without cause.
22Unless otherwise specified, such termination of eligibility or
23disenrollment is not subject to the Department's hearing
24process. However, a disenrolled vendor may reapply without
26    The Department has the discretion to limit the conditional



HB2050- 22 -LRB103 03523 KTG 48529 b

1enrollment period for vendors based upon category of risk of
2the vendor.
3    Prior to enrollment and during the conditional enrollment
4period in the medical assistance program, all vendors shall be
5subject to enhanced oversight, screening, and review based on
6the risk of fraud, waste, and abuse that is posed by the
7category of risk of the vendor. The Illinois Department shall
8establish the procedures for oversight, screening, and review,
9which may include, but need not be limited to: criminal and
10financial background checks; fingerprinting; license,
11certification, and authorization verifications; unscheduled or
12unannounced site visits; database checks; prepayment audit
13reviews; audits; payment caps; payment suspensions; and other
14screening as required by federal or State law.
15    The Department shall define or specify the following: (i)
16by provider notice, the "category of risk of the vendor" for
17each type of vendor, which shall take into account the level of
18screening applicable to a particular category of vendor under
19federal law and regulations; (ii) by rule or provider notice,
20the maximum length of the conditional enrollment period for
21each category of risk of the vendor; and (iii) by rule, the
22hearing rights, if any, afforded to a vendor in each category
23of risk of the vendor that is terminated or disenrolled during
24the conditional enrollment period.
25    To be eligible for payment consideration, a vendor's
26payment claim or bill, either as an initial claim or as a



HB2050- 23 -LRB103 03523 KTG 48529 b

1resubmitted claim following prior rejection, must be received
2by the Illinois Department, or its fiscal intermediary, no
3later than 180 days after the latest date on the claim on which
4medical goods or services were provided, with the following
6        (1) In the case of a provider whose enrollment is in
7    process by the Illinois Department, the 180-day period
8    shall not begin until the date on the written notice from
9    the Illinois Department that the provider enrollment is
10    complete.
11        (2) In the case of errors attributable to the Illinois
12    Department or any of its claims processing intermediaries
13    which result in an inability to receive, process, or
14    adjudicate a claim, the 180-day period shall not begin
15    until the provider has been notified of the error.
16        (3) In the case of a provider for whom the Illinois
17    Department initiates the monthly billing process.
18        (4) In the case of a provider operated by a unit of
19    local government with a population exceeding 3,000,000
20    when local government funds finance federal participation
21    for claims payments.
22    For claims for services rendered during a period for which
23a recipient received retroactive eligibility, claims must be
24filed within 180 days after the Department determines the
25applicant is eligible. For claims for which the Illinois
26Department is not the primary payer, claims must be submitted



HB2050- 24 -LRB103 03523 KTG 48529 b

1to the Illinois Department within 180 days after the final
2adjudication by the primary payer.
3    In the case of long term care facilities, within 120
4calendar days of receipt by the facility of required
5prescreening information, new admissions with associated
6admission documents shall be submitted through the Medical
7Electronic Data Interchange (MEDI) or the Recipient
8Eligibility Verification (REV) System or shall be submitted
9directly to the Department of Human Services using required
10admission forms. Effective September 1, 2014, admission
11documents, including all prescreening information, must be
12submitted through MEDI or REV. Confirmation numbers assigned
13to an accepted transaction shall be retained by a facility to
14verify timely submittal. Once an admission transaction has
15been completed, all resubmitted claims following prior
16rejection are subject to receipt no later than 180 days after
17the admission transaction has been completed.
18    Claims that are not submitted and received in compliance
19with the foregoing requirements shall not be eligible for
20payment under the medical assistance program, and the State
21shall have no liability for payment of those claims.
22    To the extent consistent with applicable information and
23privacy, security, and disclosure laws, State and federal
24agencies and departments shall provide the Illinois Department
25access to confidential and other information and data
26necessary to perform eligibility and payment verifications and



HB2050- 25 -LRB103 03523 KTG 48529 b

1other Illinois Department functions. This includes, but is not
2limited to: information pertaining to licensure;
3certification; earnings; immigration status; citizenship; wage
4reporting; unearned and earned income; pension income;
5employment; supplemental security income; social security
6numbers; National Provider Identifier (NPI) numbers; the
7National Practitioner Data Bank (NPDB); program and agency
8exclusions; taxpayer identification numbers; tax delinquency;
9corporate information; and death records.
10    The Illinois Department shall enter into agreements with
11State agencies and departments, and is authorized to enter
12into agreements with federal agencies and departments, under
13which such agencies and departments shall share data necessary
14for medical assistance program integrity functions and
15oversight. The Illinois Department shall develop, in
16cooperation with other State departments and agencies, and in
17compliance with applicable federal laws and regulations,
18appropriate and effective methods to share such data. At a
19minimum, and to the extent necessary to provide data sharing,
20the Illinois Department shall enter into agreements with State
21agencies and departments, and is authorized to enter into
22agreements with federal agencies and departments, including,
23but not limited to: the Secretary of State; the Department of
24Revenue; the Department of Public Health; the Department of
25Human Services; and the Department of Financial and
26Professional Regulation.



HB2050- 26 -LRB103 03523 KTG 48529 b

1    Beginning in fiscal year 2013, the Illinois Department
2shall set forth a request for information to identify the
3benefits of a pre-payment, post-adjudication, and post-edit
4claims system with the goals of streamlining claims processing
5and provider reimbursement, reducing the number of pending or
6rejected claims, and helping to ensure a more transparent
7adjudication process through the utilization of: (i) provider
8data verification and provider screening technology; and (ii)
9clinical code editing; and (iii) pre-pay, pre- or
10post-adjudicated predictive modeling with an integrated case
11management system with link analysis. Such a request for
12information shall not be considered as a request for proposal
13or as an obligation on the part of the Illinois Department to
14take any action or acquire any products or services.
15    The Illinois Department shall establish policies,
16procedures, standards and criteria by rule for the
17acquisition, repair and replacement of orthotic and prosthetic
18devices and durable medical equipment. Such rules shall
19provide, but not be limited to, the following services: (1)
20immediate repair or replacement of such devices by recipients;
21and (2) rental, lease, purchase or lease-purchase of durable
22medical equipment in a cost-effective manner, taking into
23consideration the recipient's medical prognosis, the extent of
24the recipient's needs, and the requirements and costs for
25maintaining such equipment. Subject to prior approval, such
26rules shall enable a recipient to temporarily acquire and use



HB2050- 27 -LRB103 03523 KTG 48529 b

1alternative or substitute devices or equipment pending repairs
2or replacements of any device or equipment previously
3authorized for such recipient by the Department.
4Notwithstanding any provision of Section 5-5f to the contrary,
5the Department may, by rule, exempt certain replacement
6wheelchair parts from prior approval and, for wheelchairs,
7wheelchair parts, wheelchair accessories, and related seating
8and positioning items, determine the wholesale price by
9methods other than actual acquisition costs.
10    The Department shall require, by rule, all providers of
11durable medical equipment to be accredited by an accreditation
12organization approved by the federal Centers for Medicare and
13Medicaid Services and recognized by the Department in order to
14bill the Department for providing durable medical equipment to
15recipients. No later than 15 months after the effective date
16of the rule adopted pursuant to this paragraph, all providers
17must meet the accreditation requirement.
18    In order to promote environmental responsibility, meet the
19needs of recipients and enrollees, and achieve significant
20cost savings, the Department, or a managed care organization
21under contract with the Department, may provide recipients or
22managed care enrollees who have a prescription or Certificate
23of Medical Necessity access to refurbished durable medical
24equipment under this Section (excluding prosthetic and
25orthotic devices as defined in the Orthotics, Prosthetics, and
26Pedorthics Practice Act and complex rehabilitation technology



HB2050- 28 -LRB103 03523 KTG 48529 b

1products and associated services) through the State's
2assistive technology program's reutilization program, using
3staff with the Assistive Technology Professional (ATP)
4Certification if the refurbished durable medical equipment:
5(i) is available; (ii) is less expensive, including shipping
6costs, than new durable medical equipment of the same type;
7(iii) is able to withstand at least 3 years of use; (iv) is
8cleaned, disinfected, sterilized, and safe in accordance with
9federal Food and Drug Administration regulations and guidance
10governing the reprocessing of medical devices in health care
11settings; and (v) equally meets the needs of the recipient or
12enrollee. The reutilization program shall confirm that the
13recipient or enrollee is not already in receipt of the same or
14similar equipment from another service provider, and that the
15refurbished durable medical equipment equally meets the needs
16of the recipient or enrollee. Nothing in this paragraph shall
17be construed to limit recipient or enrollee choice to obtain
18new durable medical equipment or place any additional prior
19authorization conditions on enrollees of managed care
21    The Department shall execute, relative to the nursing home
22prescreening project, written inter-agency agreements with the
23Department of Human Services and the Department on Aging, to
24effect the following: (i) intake procedures and common
25eligibility criteria for those persons who are receiving
26non-institutional services; and (ii) the establishment and



HB2050- 29 -LRB103 03523 KTG 48529 b

1development of non-institutional services in areas of the
2State where they are not currently available or are
3undeveloped; and (iii) notwithstanding any other provision of
4law, subject to federal approval, on and after July 1, 2012, an
5increase in the determination of need (DON) scores from 29 to
637 for applicants for institutional and home and
7community-based long term care; if and only if federal
8approval is not granted, the Department may, in conjunction
9with other affected agencies, implement utilization controls
10or changes in benefit packages to effectuate a similar savings
11amount for this population; and (iv) no later than July 1,
122013, minimum level of care eligibility criteria for
13institutional and home and community-based long term care; and
14(v) no later than October 1, 2013, establish procedures to
15permit long term care providers access to eligibility scores
16for individuals with an admission date who are seeking or
17receiving services from the long term care provider. In order
18to select the minimum level of care eligibility criteria, the
19Governor shall establish a workgroup that includes affected
20agency representatives and stakeholders representing the
21institutional and home and community-based long term care
22interests. This Section shall not restrict the Department from
23implementing lower level of care eligibility criteria for
24community-based services in circumstances where federal
25approval has been granted.
26    The Illinois Department shall develop and operate, in



HB2050- 30 -LRB103 03523 KTG 48529 b

1cooperation with other State Departments and agencies and in
2compliance with applicable federal laws and regulations,
3appropriate and effective systems of health care evaluation
4and programs for monitoring of utilization of health care
5services and facilities, as it affects persons eligible for
6medical assistance under this Code.
7    The Illinois Department shall report annually to the
8General Assembly, no later than the second Friday in April of
91979 and each year thereafter, in regard to:
10        (a) actual statistics and trends in utilization of
11    medical services by public aid recipients;
12        (b) actual statistics and trends in the provision of
13    the various medical services by medical vendors;
14        (c) current rate structures and proposed changes in
15    those rate structures for the various medical vendors; and
16        (d) efforts at utilization review and control by the
17    Illinois Department.
18    The period covered by each report shall be the 3 years
19ending on the June 30 prior to the report. The report shall
20include suggested legislation for consideration by the General
21Assembly. The requirement for reporting to the General
22Assembly shall be satisfied by filing copies of the report as
23required by Section 3.1 of the General Assembly Organization
24Act, and filing such additional copies with the State
25Government Report Distribution Center for the General Assembly
26as is required under paragraph (t) of Section 7 of the State



HB2050- 31 -LRB103 03523 KTG 48529 b

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



HB2050- 32 -LRB103 03523 KTG 48529 b

1and the services under this Section shall be limited to
2services associated with kidney transplantation.
3    Notwithstanding any other provision of this Code to the
4contrary, on or after July 1, 2015, all FDA approved forms of
5medication assisted treatment prescribed for the treatment of
6alcohol dependence or treatment of opioid dependence shall be
7covered under both fee for service and managed care medical
8assistance programs for persons who are otherwise eligible for
9medical assistance under this Article and shall not be subject
10to any (1) utilization control, other than those established
11under the American Society of Addiction Medicine patient
12placement criteria, (2) prior authorization mandate, or (3)
13lifetime restriction limit mandate.
14    On or after July 1, 2015, opioid antagonists prescribed
15for the treatment of an opioid overdose, including the
16medication product, administration devices, and any pharmacy
17fees or hospital fees related to the dispensing, distribution,
18and administration of the opioid antagonist, shall be covered
19under the medical assistance program for persons who are
20otherwise eligible for medical assistance under this Article.
21As used in this Section, "opioid antagonist" means a drug that
22binds to opioid receptors and blocks or inhibits the effect of
23opioids acting on those receptors, including, but not limited
24to, naloxone hydrochloride or any other similarly acting drug
25approved by the U.S. Food and Drug Administration. The
26Department shall not impose a copayment on the coverage



HB2050- 33 -LRB103 03523 KTG 48529 b

1provided for naloxone hydrochloride under the medical
2assistance program.
3    Upon federal approval, the Department shall provide
4coverage and reimbursement for all drugs that are approved for
5marketing by the federal Food and Drug Administration and that
6are recommended by the federal Public Health Service or the
7United States Centers for Disease Control and Prevention for
8pre-exposure prophylaxis and related pre-exposure prophylaxis
9services, including, but not limited to, HIV and sexually
10transmitted infection screening, treatment for sexually
11transmitted infections, medical monitoring, assorted labs, and
12counseling to reduce the likelihood of HIV infection among
13individuals who are not infected with HIV but who are at high
14risk of HIV infection.
15    A federally qualified health center, as defined in Section
161905(l)(2)(B) of the federal Social Security Act, shall be
17reimbursed by the Department in accordance with the federally
18qualified health center's encounter rate for services provided
19to medical assistance recipients that are performed by a
20dental hygienist, as defined under the Illinois Dental
21Practice Act, working under the general supervision of a
22dentist and employed by a federally qualified health center.
23    Within 90 days after October 8, 2021 (the effective date
24of Public Act 102-665), the Department shall seek federal
25approval of a State Plan amendment to expand coverage for
26family planning services that includes presumptive eligibility



HB2050- 34 -LRB103 03523 KTG 48529 b

1to individuals whose income is at or below 208% of the federal
2poverty level. Coverage under this Section shall be effective
3beginning no later than December 1, 2022.
4    Subject to approval by the federal Centers for Medicare
5and Medicaid Services of a Title XIX State Plan amendment
6electing the Program of All-Inclusive Care for the Elderly
7(PACE) as a State Medicaid option, as provided for by Subtitle
8I (commencing with Section 4801) of Title IV of the Balanced
9Budget Act of 1997 (Public Law 105-33) and Part 460
10(commencing with Section 460.2) of Subchapter E of Title 42 of
11the Code of Federal Regulations, PACE program services shall
12become a covered benefit of the medical assistance program,
13subject to criteria established in accordance with all
14applicable laws.
15    Notwithstanding any other provision of this Code,
16community-based pediatric palliative care from a trained
17interdisciplinary team shall be covered under the medical
18assistance program as provided in Section 15 of the Pediatric
19Palliative Care Act.
20    Notwithstanding any other provision of this Code, within
2112 months after June 2, 2022 (the effective date of Public Act
22102-1037) this amendatory Act of the 102nd General Assembly
23and subject to federal approval, acupuncture services
24performed by an acupuncturist licensed under the Acupuncture
25Practice Act who is acting within the scope of his or her
26license shall be covered under the medical assistance program.



HB2050- 35 -LRB103 03523 KTG 48529 b

1The Department shall apply for any federal waiver or State
2Plan amendment, if required, to implement this paragraph. The
3Department may adopt any rules, including standards and
4criteria, necessary to implement this paragraph.
5(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
6102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
735, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
855-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
9102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
101-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
11102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
121-1-23; revised 8-9-22.)
13    (305 ILCS 5/5-5.06f new)
14    Sec. 5-5.06f. Medically necessary orthodontic services;
15criteria for coverage.
16    (a) As used in this Section, "medically necessary
17orthodontic services" means orthodontic services to prevent,
18diagnose, minimize, alleviate, correct, or resolve a
19malocclusion (including craniofacial abnormalities and
20traumatic or pathologic anatomical deviations) that causes
21pain or suffering, physical deformity, or significant
22malfunction, that aggravates another condition, or that
23results in further injury or infirmity.
24    (b) On and after July 1, 2023, the Department shall use the
25following auto-qualifiers when determining whether an



HB2050- 36 -LRB103 03523 KTG 48529 b

1individual, who is otherwise eligible for medical assistance,
2is also eligible for coverage for a medically necessary
3orthodontic service:
4        (1) Overjet: 9 mm or more.
5        (2) Reverse overjet: 3.5 mm or more.
6        (3) Anterior or posterior crossbite of 3 or more teeth
7    per arch.
8        (4) Lateral or anterior open bite: 2 mm or more, of 4
9    or more teeth per arch.
10        (5) Impinging overbite with evidence of occlusal
11    contact into the opposing soft tissue.
12        (6) Impactions where eruption is impeded, but
13    extraction is not indicated (excluding third molars).
14        (7) Jaws or dentition which are profoundly affected by
15    a congenital or developmental disorder (craniofacial
16    anomalies), trauma, or pathology.
17        (8) Congenitally missing teeth (excluding third
18    molars) of at least one tooth per quadrant.
19        (9) Crowding or spacing of 10 mm or more, in either the
20    maxillary or mandibular arch (excluding third molars).
21    (c) If the Department denies a claim for a medically
22necessary orthodontic service, the Department must, at a
23minimum, provide the following information to the provider of
24the orthodontic service:
25        (1) The actual score of the orthodontic case.
26        (2) The name of the dentist or orthodontist who scored



HB2050- 37 -LRB103 03523 KTG 48529 b

1    the orthodontic case.
2        (3) A detailed scoring sheet outlining the reasons for
3    the score of the orthodontic case.
4        (4) Instructions on how to appeal the denied claim.