State of Illinois
2021 and 2022


Introduced 2/17/2021, by Sen. Michael E. Hastings


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that beginning July 1, 2021, all FDA approved prescription medications that are recognized by a generally accepted standard medical reference as effective in the treatment of conditions specified in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association must be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance and shall not be subject to any (i) utilization control, (ii) prior authorization mandate, or (iii) lifetime restriction limit mandate. Effective July 1, 2021.

LRB102 10959 KTG 16291 b






SB0270LRB102 10959 KTG 16291 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 1. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing
16home, or elsewhere; (6) medical care, or any other type of
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant women, provided by an individual licensed to
22practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or



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1corrective procedures provided by or under the supervision of
2a dentist in the practice of his or her profession; (11)
3physical therapy and related services; (12) prescribed drugs,
4dentures, and prosthetic devices; and eyeglasses prescribed by
5a physician skilled in the diseases of the eye, or by an
6optometrist, whichever the person may select; (13) other
7diagnostic, screening, preventive, and rehabilitative
8services, including to ensure that the individual's need for
9intervention or treatment of mental disorders or substance use
10disorders or co-occurring mental health and substance use
11disorders is determined using a uniform screening, assessment,
12and evaluation process inclusive of criteria, for children and
13adults; for purposes of this item (13), a uniform screening,
14assessment, and evaluation process refers to a process that
15includes an appropriate evaluation and, as warranted, a
16referral; "uniform" does not mean the use of a singular
17instrument, tool, or process that all must utilize; (14)
18transportation and such other expenses as may be necessary;
19(15) medical treatment of sexual assault survivors, as defined
20in Section 1a of the Sexual Assault Survivors Emergency
21Treatment Act, for injuries sustained as a result of the
22sexual assault, including examinations and laboratory tests to
23discover evidence which may be used in criminal proceedings
24arising from the sexual assault; (16) the diagnosis and
25treatment of sickle cell anemia; and (17) any other medical
26care, and any other type of remedial care recognized under the



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1laws of this State. The term "any other type of remedial care"
2shall include nursing care and nursing home service for
3persons who rely on treatment by spiritual means alone through
4prayer for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance
16under this Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a



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



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



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1enrolling as a participating provider in the medical
2assistance program. A not-for-profit health clinic shall
3include a public health clinic or Federally Qualified Health
4Center or other enrolled provider, as determined by the
5Department, through which dental services covered under this
6Section are performed. The Department shall establish a
7process for payment of claims for reimbursement for covered
8dental services rendered under this provision.
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 women
2335 years of age or older who are eligible for medical
24assistance under this Article, as follows:
25        (A) A baseline mammogram for women 35 to 39 years of
26    age.



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1        (B) An annual mammogram for women 40 years of age or
2    older.
3        (C) A mammogram at the age and intervals considered
4    medically necessary by the woman's health care provider
5    for women under 40 years of age and having a family history
6    of breast cancer, prior personal history of breast cancer,
7    positive genetic testing, or other risk factors.
8        (D) A comprehensive ultrasound screening and MRI of an
9    entire breast or breasts if a mammogram demonstrates
10    heterogeneous or dense breast tissue or when medically
11    necessary as determined by a physician licensed to
12    practice medicine in all of its branches.
13        (E) A screening MRI when medically necessary, as
14    determined by a physician licensed to practice medicine in
15    all of its branches.
16        (F) A diagnostic mammogram when medically necessary,
17    as determined by a physician licensed to practice medicine
18    in all its branches, advanced practice registered nurse,
19    or physician assistant.
20    The Department shall not impose a deductible, coinsurance,
21copayment, or any other cost-sharing requirement on the
22coverage provided under this paragraph; except that this
23sentence does not apply to coverage of diagnostic mammograms
24to the extent such coverage would disqualify a high-deductible
25health plan from eligibility for a health savings account
26pursuant to Section 223 of the Internal Revenue Code (26



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



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1agency, promulgates rules or regulations to be published in
2the Federal Register or publishes a comment in the Federal
3Register or issues an opinion, guidance, or other action that
4would require the State, pursuant to any provision of the
5Patient Protection and Affordable Care Act (Public Law
6111-148), including, but not limited to, 42 U.S.C.
718031(d)(3)(B) or any successor provision, to defray the cost
8of any coverage for breast tomosynthesis outlined in this
9paragraph, then the requirement that an insurer cover breast
10tomosynthesis is inoperative other than any such coverage
11authorized under Section 1902 of the Social Security Act, 42
12U.S.C. 1396a, and the State shall not assume any obligation
13for the cost of coverage for breast tomosynthesis set forth in
14this paragraph.
15    On and after January 1, 2016, the Department shall ensure
16that all networks of care for adult clients of the Department
17include access to at least one breast imaging Center of
18Imaging Excellence as certified by the American College of
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall
22be reimbursed for screening and diagnostic mammography at the
23same rate as the Medicare program's rates, including the
24increased reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography



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1facilities, and doctors, including radiologists, to establish
2quality standards for mammography.
3    On and after January 1, 2017, providers participating in a
4breast cancer treatment quality improvement program approved
5by the Department shall be reimbursed for breast cancer
6treatment at a rate that is no lower than 95% of the Medicare
7program's rates for the data elements included in the breast
8cancer treatment quality program.
9    The Department shall convene an expert panel, including
10representatives of hospitals, free-standing breast cancer
11treatment centers, breast cancer quality organizations, and
12doctors, including breast surgeons, reconstructive breast
13surgeons, oncologists, and primary care providers to establish
14quality standards for breast cancer treatment.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities. By January 1, 2016, the
20Department shall report to the General Assembly on the status
21of the provision set forth in this paragraph.
22    The Department shall establish a methodology to remind
23women who are age-appropriate for screening mammography, but
24who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening
26mammography. The Department shall work with experts in breast



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1cancer outreach and patient navigation to optimize these
2reminders and shall establish a methodology for evaluating
3their effectiveness and modifying the methodology based on the
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot
14program in areas of the State with the highest incidence of
15mortality related to breast cancer. At least one pilot program
16site shall be in the metropolitan Chicago area and at least one
17site shall be outside the metropolitan Chicago area. On or
18after July 1, 2016, the pilot program shall be expanded to
19include one site in western Illinois, one site in southern
20Illinois, one site in central Illinois, and 4 sites within
21metropolitan Chicago. An evaluation of the pilot program shall
22be carried out measuring health outcomes and cost of care for
23those served by the pilot program compared to similarly
24situated patients who are not served by the pilot program.
25    The Department shall require all networks of care to
26develop a means either internally or by contract with experts



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1in navigation and community outreach to navigate cancer
2patients to comprehensive care in a timely fashion. The
3Department shall require all networks of care to include
4access for patients diagnosed with cancer to at least one
5academic commission on cancer-accredited cancer program as an
6in-network covered benefit.
7    Any medical or health care provider shall immediately
8recommend, to any pregnant woman who is being provided
9prenatal services and is suspected of having a substance use
10disorder as defined in the Substance Use Disorder Act,
11referral to a local substance use disorder treatment program
12licensed by the Department of Human Services or to a licensed
13hospital which provides substance abuse treatment services.
14The Department of Healthcare and Family Services shall assure
15coverage for the cost of treatment of the drug abuse or
16addiction for pregnant recipients in accordance with the
17Illinois Medicaid Program in conjunction with the Department
18of Human Services.
19    All medical providers providing medical assistance to
20pregnant women under this Code shall receive information from
21the Department on the availability of services under any
22program providing case management services for addicted women,
23including information on appropriate referrals for other
24social services that may be needed by addicted women in
25addition to treatment for addiction.
26    The Illinois Department, in cooperation with the



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1Departments of Human Services (as successor to the Department
2of Alcoholism and Substance Abuse) and Public Health, through
3a public awareness campaign, may provide information
4concerning treatment for alcoholism and drug abuse and
5addiction, prenatal health care, and other pertinent programs
6directed at reducing the number of drug-affected infants born
7to recipients of medical assistance.
8    Neither the Department of Healthcare and Family Services
9nor the Department of Human Services shall sanction the
10recipient solely on the basis of her substance abuse.
11    The Illinois Department shall establish such regulations
12governing the dispensing of health services under this Article
13as it shall deem appropriate. The Department should seek the
14advice of formal professional advisory committees appointed by
15the Director of the Illinois Department for the purpose of
16providing regular advice on policy and administrative matters,
17information dissemination and educational activities for
18medical and health care providers, and consistency in
19procedures to the Illinois Department.
20    The Illinois Department may develop and contract with
21Partnerships of medical providers to arrange medical services
22for persons eligible under Section 5-2 of this Code.
23Implementation of this Section may be by demonstration
24projects in certain geographic areas. The Partnership shall be
25represented by a sponsor organization. The Department, by
26rule, shall develop qualifications for sponsors of



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1Partnerships. Nothing in this Section shall be construed to
2require that the sponsor organization be a medical
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and
13the Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by
17    the Partnership may receive an additional surcharge for
18    such services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain



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1qualifications to participate in Partnerships to ensure the
2delivery of high quality medical services. These
3qualifications shall be determined by rule of the Illinois
4Department and may be higher than qualifications for
5participation in the medical assistance program. Partnership
6sponsors may prescribe reasonable additional qualifications
7for participation by medical providers, only with the prior
8written approval of the Illinois Department.
9    Nothing in this Section shall limit the free choice of
10practitioners, hospitals, and other providers of medical
11services by clients. In order to ensure patient freedom of
12choice, the Illinois Department shall immediately promulgate
13all rules and take all other necessary actions so that
14provided services may be accessed from therapeutically
15certified optometrists to the full extent of the Illinois
16Optometric Practice Act of 1987 without discriminating between
17service providers.
18    The Department shall apply for a waiver from the United
19States Health Care Financing Administration to allow for the
20implementation of Partnerships under this Section.
21    The Illinois Department shall require health care
22providers to maintain records that document the medical care
23and services provided to recipients of Medical Assistance
24under this Article. Such records must be retained for a period
25of not less than 6 years from the date of service or as
26provided by applicable State law, whichever period is longer,



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1except that if an audit is initiated within the required
2retention period then the records must be retained until the
3audit is completed and every exception is resolved. The
4Illinois Department shall require health care providers to
5make available, when authorized by the patient, in writing,
6the medical records in a timely fashion to other health care
7providers who are treating or serving persons eligible for
8Medical Assistance under this Article. All dispensers of
9medical services shall be required to maintain and retain
10business and professional records sufficient to fully and
11accurately document the nature, scope, details and receipt of
12the health care provided to persons eligible for medical
13assistance under this Code, in accordance with regulations
14promulgated by the Illinois Department. The rules and
15regulations shall require that proof of the receipt of
16prescription drugs, dentures, prosthetic devices and
17eyeglasses by eligible persons under this Section accompany
18each claim for reimbursement submitted by the dispenser of
19such medical services. No such claims for reimbursement shall
20be approved for payment by the Illinois Department without
21such proof of receipt, unless the Illinois Department shall
22have put into effect and shall be operating a system of
23post-payment audit and review which shall, on a sampling
24basis, be deemed adequate by the Illinois Department to assure
25that such drugs, dentures, prosthetic devices and eyeglasses
26for which payment is being made are actually being received by



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1eligible recipients. Within 90 days after September 16, 1984
2(the effective date of Public Act 83-1439), the Illinois
3Department shall establish a current list of acquisition costs
4for all prosthetic devices and any other items recognized as
5medical equipment and supplies reimbursable under this Article
6and shall update such list on a quarterly basis, except that
7the acquisition costs of all prescription drugs shall be
8updated no less frequently than every 30 days as required by
9Section 5-5.12.
10    Notwithstanding any other law to the contrary, the
11Illinois Department shall, within 365 days after July 22, 2013
12(the effective date of Public Act 98-104), establish
13procedures to permit skilled care facilities licensed under
14the Nursing Home Care Act to submit monthly billing claims for
15reimbursement purposes. Following development of these
16procedures, the Department shall, by July 1, 2016, test the
17viability of the new system and implement any necessary
18operational or structural changes to its information
19technology platforms in order to allow for the direct
20acceptance and payment of nursing home claims.
21    Notwithstanding any other law to the contrary, the
22Illinois Department shall, within 365 days after August 15,
232014 (the effective date of Public Act 98-963), establish
24procedures to permit ID/DD facilities licensed under the ID/DD
25Community Care Act and MC/DD facilities licensed under the
26MC/DD Act to submit monthly billing claims for reimbursement



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1purposes. Following development of these procedures, the
2Department shall have an additional 365 days to test the
3viability of the new system and to ensure that any necessary
4operational or structural changes to its information
5technology platforms are implemented.
6    The Illinois Department shall require all dispensers of
7medical services, other than an individual practitioner or
8group of practitioners, desiring to participate in the Medical
9Assistance program established under this Article to disclose
10all financial, beneficial, ownership, equity, surety or other
11interests in any and all firms, corporations, partnerships,
12associations, business enterprises, joint ventures, agencies,
13institutions or other legal entities providing any form of
14health care services in this State under this Article.
15    The Illinois Department may require that all dispensers of
16medical services desiring to participate in the medical
17assistance program established under this Article disclose,
18under such terms and conditions as the Illinois Department may
19by rule establish, all inquiries from clients and attorneys
20regarding medical bills paid by the Illinois Department, which
21inquiries could indicate potential existence of claims or
22liens for the Illinois Department.
23    Enrollment of a vendor shall be subject to a provisional
24period and shall be conditional for one year. During the
25period of conditional enrollment, the Department may terminate
26the vendor's eligibility to participate in, or may disenroll



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1the vendor from, the medical assistance program without cause.
2Unless otherwise specified, such termination of eligibility or
3disenrollment is not subject to the Department's hearing
4process. However, a disenrolled vendor may reapply without
6    The Department has the discretion to limit the conditional
7enrollment period for vendors based upon category of risk of
8the vendor.
9    Prior to enrollment and during the conditional enrollment
10period in the medical assistance program, all vendors shall be
11subject to enhanced oversight, screening, and review based on
12the risk of fraud, waste, and abuse that is posed by the
13category of risk of the vendor. The Illinois Department shall
14establish the procedures for oversight, screening, and review,
15which may include, but need not be limited to: criminal and
16financial background checks; fingerprinting; license,
17certification, and authorization verifications; unscheduled or
18unannounced site visits; database checks; prepayment audit
19reviews; audits; payment caps; payment suspensions; and other
20screening as required by federal or State law.
21    The Department shall define or specify the following: (i)
22by provider notice, the "category of risk of the vendor" for
23each type of vendor, which shall take into account the level of
24screening applicable to a particular category of vendor under
25federal law and regulations; (ii) by rule or provider notice,
26the maximum length of the conditional enrollment period for



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1each category of risk of the vendor; and (iii) by rule, the
2hearing rights, if any, afforded to a vendor in each category
3of risk of the vendor that is terminated or disenrolled during
4the conditional enrollment period.
5    To be eligible for payment consideration, a vendor's
6payment claim or bill, either as an initial claim or as a
7resubmitted claim following prior rejection, must be received
8by the Illinois Department, or its fiscal intermediary, no
9later than 180 days after the latest date on the claim on which
10medical goods or services were provided, with the following
12        (1) In the case of a provider whose enrollment is in
13    process by the Illinois Department, the 180-day period
14    shall not begin until the date on the written notice from
15    the Illinois Department that the provider enrollment is
16    complete.
17        (2) In the case of errors attributable to the Illinois
18    Department or any of its claims processing intermediaries
19    which result in an inability to receive, process, or
20    adjudicate a claim, the 180-day period shall not begin
21    until the provider has been notified of the error.
22        (3) In the case of a provider for whom the Illinois
23    Department initiates the monthly billing process.
24        (4) In the case of a provider operated by a unit of
25    local government with a population exceeding 3,000,000
26    when local government funds finance federal participation



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1    for claims payments.
2    For claims for services rendered during a period for which
3a recipient received retroactive eligibility, claims must be
4filed within 180 days after the Department determines the
5applicant is eligible. For claims for which the Illinois
6Department is not the primary payer, claims must be submitted
7to the Illinois Department within 180 days after the final
8adjudication by the primary payer.
9    In the case of long term care facilities, within 45
10calendar days of receipt by the facility of required
11prescreening information, new admissions with associated
12admission documents shall be submitted through the Medical
13Electronic Data Interchange (MEDI) or the Recipient
14Eligibility Verification (REV) System or shall be submitted
15directly to the Department of Human Services using required
16admission forms. Effective September 1, 2014, admission
17documents, including all prescreening information, must be
18submitted through MEDI or REV. Confirmation numbers assigned
19to an accepted transaction shall be retained by a facility to
20verify timely submittal. Once an admission transaction has
21been completed, all resubmitted claims following prior
22rejection are subject to receipt no later than 180 days after
23the admission transaction has been completed.
24    Claims that are not submitted and received in compliance
25with the foregoing requirements shall not be eligible for
26payment under the medical assistance program, and the State



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1shall have no liability for payment of those claims.
2    To the extent consistent with applicable information and
3privacy, security, and disclosure laws, State and federal
4agencies and departments shall provide the Illinois Department
5access to confidential and other information and data
6necessary to perform eligibility and payment verifications and
7other Illinois Department functions. This includes, but is not
8limited to: information pertaining to licensure;
9certification; earnings; immigration status; citizenship; wage
10reporting; unearned and earned income; pension income;
11employment; supplemental security income; social security
12numbers; National Provider Identifier (NPI) numbers; the
13National Practitioner Data Bank (NPDB); program and agency
14exclusions; taxpayer identification numbers; tax delinquency;
15corporate information; and death records.
16    The Illinois Department shall enter into agreements with
17State agencies and departments, and is authorized to enter
18into agreements with federal agencies and departments, under
19which such agencies and departments shall share data necessary
20for medical assistance program integrity functions and
21oversight. The Illinois Department shall develop, in
22cooperation with other State departments and agencies, and in
23compliance with applicable federal laws and regulations,
24appropriate and effective methods to share such data. At a
25minimum, and to the extent necessary to provide data sharing,
26the Illinois Department shall enter into agreements with State



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1agencies and departments, and is authorized to enter into
2agreements with federal agencies and departments, including,
3but not limited to: the Secretary of State; the Department of
4Revenue; the Department of Public Health; the Department of
5Human Services; and the Department of Financial and
6Professional Regulation.
7    Beginning in fiscal year 2013, the Illinois Department
8shall set forth a request for information to identify the
9benefits of a pre-payment, post-adjudication, and post-edit
10claims system with the goals of streamlining claims processing
11and provider reimbursement, reducing the number of pending or
12rejected claims, and helping to ensure a more transparent
13adjudication process through the utilization of: (i) provider
14data verification and provider screening technology; and (ii)
15clinical code editing; and (iii) pre-pay, pre- or
16post-adjudicated predictive modeling with an integrated case
17management system with link analysis. Such a request for
18information shall not be considered as a request for proposal
19or as an obligation on the part of the Illinois Department to
20take any action or acquire any products or services.
21    The Illinois Department shall establish policies,
22procedures, standards and criteria by rule for the
23acquisition, repair and replacement of orthotic and prosthetic
24devices and durable medical equipment. Such rules shall
25provide, but not be limited to, the following services: (1)
26immediate repair or replacement of such devices by recipients;



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1and (2) rental, lease, purchase or lease-purchase of durable
2medical equipment in a cost-effective manner, taking into
3consideration the recipient's medical prognosis, the extent of
4the recipient's needs, and the requirements and costs for
5maintaining such equipment. Subject to prior approval, such
6rules shall enable a recipient to temporarily acquire and use
7alternative or substitute devices or equipment pending repairs
8or replacements of any device or equipment previously
9authorized for such recipient by the Department.
10Notwithstanding any provision of Section 5-5f to the contrary,
11the Department may, by rule, exempt certain replacement
12wheelchair parts from prior approval and, for wheelchairs,
13wheelchair parts, wheelchair accessories, and related seating
14and positioning items, determine the wholesale price by
15methods other than actual acquisition costs.
16    The Department shall require, by rule, all providers of
17durable medical equipment to be accredited by an accreditation
18organization approved by the federal Centers for Medicare and
19Medicaid Services and recognized by the Department in order to
20bill the Department for providing durable medical equipment to
21recipients. No later than 15 months after the effective date
22of the rule adopted pursuant to this paragraph, all providers
23must meet the accreditation requirement.
24    In order to promote environmental responsibility, meet the
25needs of recipients and enrollees, and achieve significant
26cost savings, the Department, or a managed care organization



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



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1    The Department shall execute, relative to the nursing home
2prescreening project, written inter-agency agreements with the
3Department of Human Services and the Department on Aging, to
4effect the following: (i) intake procedures and common
5eligibility criteria for those persons who are receiving
6non-institutional services; and (ii) the establishment and
7development of non-institutional services in areas of the
8State where they are not currently available or are
9undeveloped; and (iii) notwithstanding any other provision of
10law, subject to federal approval, on and after July 1, 2012, an
11increase in the determination of need (DON) scores from 29 to
1237 for applicants for institutional and home and
13community-based long term care; if and only if federal
14approval is not granted, the Department may, in conjunction
15with other affected agencies, implement utilization controls
16or changes in benefit packages to effectuate a similar savings
17amount for this population; and (iv) no later than July 1,
182013, minimum level of care eligibility criteria for
19institutional and home and community-based long term care; and
20(v) no later than October 1, 2013, establish procedures to
21permit long term care providers access to eligibility scores
22for individuals with an admission date who are seeking or
23receiving services from the long term care provider. In order
24to select the minimum level of care eligibility criteria, the
25Governor shall establish a workgroup that includes affected
26agency representatives and stakeholders representing the



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1institutional and home and community-based long term care
2interests. This Section shall not restrict the Department from
3implementing lower level of care eligibility criteria for
4community-based services in circumstances where federal
5approval has been granted.
6    The Illinois Department shall develop and operate, in
7cooperation with other State Departments and agencies and in
8compliance with applicable federal laws and regulations,
9appropriate and effective systems of health care evaluation
10and programs for monitoring of utilization of health care
11services and facilities, as it affects persons eligible for
12medical assistance under this Code.
13    The Illinois Department shall report annually to the
14General Assembly, no later than the second Friday in April of
151979 and each year thereafter, in regard to:
16        (a) actual statistics and trends in utilization of
17    medical services by public aid recipients;
18        (b) actual statistics and trends in the provision of
19    the various medical services by medical vendors;
20        (c) current rate structures and proposed changes in
21    those rate structures for the various medical vendors; and
22        (d) efforts at utilization review and control by the
23    Illinois Department.
24    The period covered by each report shall be the 3 years
25ending on the June 30 prior to the report. The report shall
26include suggested legislation for consideration by the General



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1Assembly. The requirement for reporting to the General
2Assembly shall be satisfied by filing copies of the report as
3required by Section 3.1 of the General Assembly Organization
4Act, and filing such additional copies with the State
5Government Report Distribution Center for the General Assembly
6as is required under paragraph (t) of Section 7 of the State
7Library Act.
8    Rulemaking authority to implement Public Act 95-1045, if
9any, is conditioned on the rules being adopted in accordance
10with all provisions of the Illinois Administrative Procedure
11Act and all rules and procedures of the Joint Committee on
12Administrative Rules; any purported rule not so adopted, for
13whatever reason, is unauthorized.
14    On and after July 1, 2012, the Department shall reduce any
15rate of reimbursement for services or other payments or alter
16any methodologies authorized by this Code to reduce any rate
17of reimbursement for services or other payments in accordance
18with Section 5-5e.
19    Because kidney transplantation can be an appropriate,
20cost-effective alternative to renal dialysis when medically
21necessary and notwithstanding the provisions of Section 1-11
22of this Code, beginning October 1, 2014, the Department shall
23cover kidney transplantation for noncitizens with end-stage
24renal disease who are not eligible for comprehensive medical
25benefits, who meet the residency requirements of Section 5-3
26of this Code, and who would otherwise meet the financial



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1requirements of the appropriate class of eligible persons
2under Section 5-2 of this Code. To qualify for coverage of
3kidney transplantation, such person must be receiving
4emergency renal dialysis services covered by the Department.
5Providers under this Section shall be prior approved and
6certified by the Department to perform kidney transplantation
7and the services under this Section shall be limited to
8services associated with kidney transplantation.
9    Notwithstanding any other provision of this Code to the
10contrary, on or after July 1, 2015, all FDA approved forms of
11medication assisted treatment prescribed for the treatment of
12alcohol dependence or treatment of opioid dependence shall be
13covered under both fee for service and managed care medical
14assistance programs for persons who are otherwise eligible for
15medical assistance under this Article and shall not be subject
16to any (1) utilization control, other than those established
17under the American Society of Addiction Medicine patient
18placement criteria, (2) prior authorization mandate, or (3)
19lifetime restriction limit mandate.
20    On or after July 1, 2015, opioid antagonists prescribed
21for the treatment of an opioid overdose, including the
22medication product, administration devices, and any pharmacy
23fees related to the dispensing and administration of the
24opioid antagonist, shall be covered under the medical
25assistance program for persons who are otherwise eligible for
26medical assistance under this Article. As used in this



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1Section, "opioid antagonist" means a drug that binds to opioid
2receptors and blocks or inhibits the effect of opioids acting
3on those receptors, including, but not limited to, naloxone
4hydrochloride or any other similarly acting drug approved by
5the U.S. Food and Drug Administration.
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    A federally qualified health center, as defined in Section
191905(l)(2)(B) of the federal Social Security Act, shall be
20reimbursed by the Department in accordance with the federally
21qualified health center's encounter rate for services provided
22to medical assistance recipients that are performed by a
23dental hygienist, as defined under the Illinois Dental
24Practice Act, working under the general supervision of a
25dentist and employed by a federally qualified health center.
26    Notwithstanding any other provision of this Code to the



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1contrary, beginning July 1, 2021, all FDA approved
2prescription medications that are recognized by a generally
3accepted standard medical reference as effective in the
4treatment of conditions specified in the most recent
5Diagnostic and Statistical Manual of Mental Disorders
6published by the American Psychiatric Association must 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 (i) utilization control, (ii) prior authorization
11mandate, or (iii) lifetime restriction limit mandate.
12(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
13100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
146-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
15eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
16100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
171-1-20; revised 9-18-19.)
18    Section 99. Effective date. This Act takes effect July 1,