Bill Text: IL HB4180 | 2023-2024 | 103rd General Assembly | Engrossed

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Bill Title: Reinserts the provisions of the bill, as amended by House Amendment No. 1, with the following changes. In the Illinois Insurance Code and the Illinois Public Aid Code, requires coverage of molecular breast imaging (MBI) of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, physician assistant, or advanced practice registered nurse (rather than as determined by a physician licensed to practice medicine in all of its branches). Amends the Counties Code, the Illinois Municipal Code, and the Health Maintenance Organization Act. In provisions concerning coverage for mammograms, provides that coverage for certain types of mammography shall be made available to patients of a specified age (rather than only women of a specified age). Makes changes to require coverage for molecular breast imaging. Effective January 1, 2026.

Spectrum: Strong Partisan Bill (Democrat 27-2)

Status: (Engrossed) 2024-04-19 - Referred to Assignments [HB4180 Detail]

Download: Illinois-2023-HB4180-Engrossed.html

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HB4180 Engrossed LRB103 34255 MXP 64081 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Counties Code is amended by changing
Section 5-1069 as follows:
(55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
Sec. 5-1069. Group life, health, accident, hospital, and
medical insurance.
(a) The county board of any county may arrange to provide,
for the benefit of employees of the county, group life,
health, accident, hospital, and medical insurance, or any one
or any combination of those types of insurance, or the county
board may self-insure, for the benefit of its employees, all
or a portion of the employees' group life, health, accident,
hospital, and medical insurance, or any one or any combination
of those types of insurance, including a combination of
self-insurance and other types of insurance authorized by this
Section, provided that the county board complies with all
other requirements of this Section. The insurance may include
provision for employees who rely on treatment by prayer or
spiritual means alone for healing in accordance with the
tenets and practice of a well recognized religious
denomination. The county board may provide for payment by the

HB4180 Engrossed - 2 - LRB103 34255 MXP 64081 b
county of a portion or all of the premium or charge for the
insurance with the employee paying the balance of the premium
or charge, if any. If the county board undertakes a plan under
which the county pays only a portion of the premium or charge,
the county board shall provide for withholding and deducting
from the compensation of those employees who consent to join
the plan the balance of the premium or charge for the
insurance.
(b) If the county board does not provide for
self-insurance or for a plan under which the county pays a
portion or all of the premium or charge for a group insurance
plan, the county board may provide for withholding and
deducting from the compensation of those employees who consent
thereto the total premium or charge for any group life,
health, accident, hospital, and medical insurance.
(c) The county board may exercise the powers granted in
this Section only if it provides for self-insurance or, where
it makes arrangements to provide group insurance through an
insurance carrier, if the kinds of group insurance are
obtained from an insurance company authorized to do business
in the State of Illinois. The county board may enact an
ordinance prescribing the method of operation of the insurance
program.
(d) If a county, including a home rule county, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the insurance coverage shall

HB4180 Engrossed - 3 - LRB103 34255 MXP 64081 b
include screening by low-dose mammography for all patients
women 35 years of age or older for the presence of occult
breast cancer unless the county elects to provide mammograms
itself under Section 5-1069.1. The coverage shall be as
follows:
(1) A baseline mammogram for patients women 35 to 39
years of age.
(2) An annual mammogram for patients women 40 years of
age or older.
(3) A mammogram at the age and intervals considered
medically necessary by the patient's woman's health care
provider for patients women under 40 years of age and
having a family history of breast cancer, prior personal
history of breast cancer, positive genetic testing, or
other risk factors.
(4) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after January 1, 2020 (the effective date of Public
Act 101-580) this amendatory Act of the 101st General
Assembly, a comprehensive ultrasound screening of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches, advanced
practice registered nurse, or physician assistant.
(4.5) For a group policy of accident and health

HB4180 Engrossed - 4 - LRB103 34255 MXP 64081 b
insurance that is amended, delivered, issued, or renewed
on or after the effective date of this amendatory Act of
the 103rd General Assembly, molecular breast imaging (MBI)
and magnetic resonance imaging of an entire breast or
breasts if a mammogram demonstrates heterogeneous or dense
breast tissue or when medically necessary as determined by
a physician licensed to practice medicine in all of its
branches, advanced practice registered nurse, or physician
assistant.
(5) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after January 1, 2020 (the effective date of Public
Act 101-580) this amendatory Act of the 101st General
Assembly, a diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
A policy subject to this subsection shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
For purposes of this subsection:

HB4180 Engrossed - 5 - LRB103 34255 MXP 64081 b
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography.
(d-5) Coverage as described by subsection (d) shall be
provided at no cost to the insured and shall not be applied to
an annual or lifetime maximum benefit.
(d-10) When health care services are available through
contracted providers and a person does not comply with plan
provisions specific to the use of contracted providers, the
requirements of subsection (d-5) are not applicable. When a
person does not comply with plan provisions specific to the
use of contracted providers, plan provisions specific to the
use of non-contracted providers must be applied without
distinction for coverage required by this Section and shall be
at least as favorable as for other radiological examinations
covered by the policy or contract.

HB4180 Engrossed - 6 - LRB103 34255 MXP 64081 b
(d-15) If a county, including a home rule county, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the insurance coverage shall
include mastectomy coverage, which includes coverage for
prosthetic devices or reconstructive surgery incident to the
mastectomy. Coverage for breast reconstruction in connection
with a mastectomy shall include:
(1) reconstruction of the breast upon which the
mastectomy has been performed;
(2) surgery and reconstruction of the other breast to
produce a symmetrical appearance; and
(3) prostheses and treatment for physical
complications at all stages of mastectomy, including
lymphedemas.
Care shall be determined in consultation with the attending
physician and the patient. The offered coverage for prosthetic
devices and reconstructive surgery shall be subject to the
deductible and coinsurance conditions applied to the
mastectomy, and all other terms and conditions applicable to
other benefits. When a mastectomy is performed and there is no
evidence of malignancy then the offered coverage may be
limited to the provision of prosthetic devices and
reconstructive surgery to within 2 years after the date of the
mastectomy. As used in this Section, "mastectomy" means the
removal of all or part of the breast for medically necessary
reasons, as determined by a licensed physician.

HB4180 Engrossed - 7 - LRB103 34255 MXP 64081 b
A county, including a home rule county, that is a
self-insurer for purposes of providing health insurance
coverage for its employees, may not penalize or reduce or
limit the reimbursement of an attending provider or provide
incentives (monetary or otherwise) to an attending provider to
induce the provider to provide care to an insured in a manner
inconsistent with this Section.
(d-20) The requirement that mammograms be included in
health insurance coverage as provided in subsections (d)
through (d-15) is an exclusive power and function of the State
and is a denial and limitation under Article VII, Section 6,
subsection (h) of the Illinois Constitution of home rule
county powers. A home rule county to which subsections (d)
through (d-15) apply must comply with every provision of those
subsections.
(e) The term "employees" as used in this Section includes
elected or appointed officials but does not include temporary
employees.
(f) The county board may, by ordinance, arrange to provide
group life, health, accident, hospital, and medical insurance,
or any one or a combination of those types of insurance, under
this Section to retired former employees and retired former
elected or appointed officials of the county.
(g) Rulemaking authority to implement this amendatory Act
of the 95th General Assembly, if any, is conditioned on the
rules being adopted in accordance with all provisions of the

HB4180 Engrossed - 8 - LRB103 34255 MXP 64081 b
Illinois Administrative Procedure Act and all rules and
procedures of the Joint Committee on Administrative Rules; any
purported rule not so adopted, for whatever reason, is
unauthorized.
(Source: P.A. 100-513, eff. 1-1-18; 101-580, eff. 1-1-20.)
Section 10. The Illinois Municipal Code is amended by
changing Section 10-4-2 as follows:
(65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
Sec. 10-4-2. Group insurance.
(a) The corporate authorities of any municipality may
arrange to provide, for the benefit of employees of the
municipality, group life, health, accident, hospital, and
medical insurance, or any one or any combination of those
types of insurance, and may arrange to provide that insurance
for the benefit of the spouses or dependents of those
employees. The insurance may include provision for employees
or other insured persons who rely on treatment by prayer or
spiritual means alone for healing in accordance with the
tenets and practice of a well recognized religious
denomination. The corporate authorities may provide for
payment by the municipality of a portion of the premium or
charge for the insurance with the employee paying the balance
of the premium or charge. If the corporate authorities
undertake a plan under which the municipality pays a portion

HB4180 Engrossed - 9 - LRB103 34255 MXP 64081 b
of the premium or charge, the corporate authorities shall
provide for withholding and deducting from the compensation of
those municipal employees who consent to join the plan the
balance of the premium or charge for the insurance.
(b) If the corporate authorities do not provide for a plan
under which the municipality pays a portion of the premium or
charge for a group insurance plan, the corporate authorities
may provide for withholding and deducting from the
compensation of those employees who consent thereto the
premium or charge for any group life, health, accident,
hospital, and medical insurance.
(c) The corporate authorities may exercise the powers
granted in this Section only if the kinds of group insurance
are obtained from an insurance company authorized to do
business in the State of Illinois, or are obtained through an
intergovernmental joint self-insurance pool as authorized
under the Intergovernmental Cooperation Act. The corporate
authorities may enact an ordinance prescribing the method of
operation of the insurance program.
(d) If a municipality, including a home rule municipality,
is a self-insurer for purposes of providing health insurance
coverage for its employees, the insurance coverage shall
include screening by low-dose mammography for all patients
women 35 years of age or older for the presence of occult
breast cancer unless the municipality elects to provide
mammograms itself under Section 10-4-2.1. The coverage shall

HB4180 Engrossed - 10 - LRB103 34255 MXP 64081 b
be as follows:
(1) A baseline mammogram for patients women 35 to 39
years of age.
(2) An annual mammogram for patients women 40 years of
age or older.
(3) A mammogram at the age and intervals considered
medically necessary by the patient's woman's health care
provider for patients women under 40 years of age and
having a family history of breast cancer, prior personal
history of breast cancer, positive genetic testing, or
other risk factors.
(4) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after January 1, 2020 (the effective date of Public
Act 101-580) this amendatory Act of the 101st General
Assembly, a comprehensive ultrasound screening of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(4.5) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after the effective date of this amendatory Act of
the 103rd General Assembly, molecular breast imaging (MBI)
and magnetic resonance imaging of an entire breast or
breasts if a mammogram demonstrates heterogeneous or dense

HB4180 Engrossed - 11 - LRB103 34255 MXP 64081 b
breast tissue or when medically necessary as determined by
a physician licensed to practice medicine in all of its
branches, advanced practice registered nurse, or physician
assistant.
(5) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after January 1, 2020, (the effective date of Public
Act 101-580) this amendatory Act of the 101st General
Assembly, a diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
A policy subject to this subsection shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
For purposes of this subsection:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a

HB4180 Engrossed - 12 - LRB103 34255 MXP 64081 b
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography.
(d-5) Coverage as described by subsection (d) shall be
provided at no cost to the insured and shall not be applied to
an annual or lifetime maximum benefit.
(d-10) When health care services are available through
contracted providers and a person does not comply with plan
provisions specific to the use of contracted providers, the
requirements of subsection (d-5) are not applicable. When a
person does not comply with plan provisions specific to the
use of contracted providers, plan provisions specific to the
use of non-contracted providers must be applied without
distinction for coverage required by this Section and shall be
at least as favorable as for other radiological examinations
covered by the policy or contract.
(d-15) If a municipality, including a home rule
municipality, is a self-insurer for purposes of providing
health insurance coverage for its employees, the insurance
coverage shall include mastectomy coverage, which includes
coverage for prosthetic devices or reconstructive surgery

HB4180 Engrossed - 13 - LRB103 34255 MXP 64081 b
incident to the mastectomy. Coverage for breast reconstruction
in connection with a mastectomy shall include:
(1) reconstruction of the breast upon which the
mastectomy has been performed;
(2) surgery and reconstruction of the other breast to
produce a symmetrical appearance; and
(3) prostheses and treatment for physical
complications at all stages of mastectomy, including
lymphedemas.
Care shall be determined in consultation with the attending
physician and the patient. The offered coverage for prosthetic
devices and reconstructive surgery shall be subject to the
deductible and coinsurance conditions applied to the
mastectomy, and all other terms and conditions applicable to
other benefits. When a mastectomy is performed and there is no
evidence of malignancy then the offered coverage may be
limited to the provision of prosthetic devices and
reconstructive surgery to within 2 years after the date of the
mastectomy. As used in this Section, "mastectomy" means the
removal of all or part of the breast for medically necessary
reasons, as determined by a licensed physician.
A municipality, including a home rule municipality, that
is a self-insurer for purposes of providing health insurance
coverage for its employees, may not penalize or reduce or
limit the reimbursement of an attending provider or provide
incentives (monetary or otherwise) to an attending provider to

HB4180 Engrossed - 14 - LRB103 34255 MXP 64081 b
induce the provider to provide care to an insured in a manner
inconsistent with this Section.
(d-20) The requirement that mammograms be included in
health insurance coverage as provided in subsections (d)
through (d-15) is an exclusive power and function of the State
and is a denial and limitation under Article VII, Section 6,
subsection (h) of the Illinois Constitution of home rule
municipality powers. A home rule municipality to which
subsections (d) through (d-15) apply must comply with every
provision of those subsections.
(e) Rulemaking authority to implement Public Act 95-1045,
if any, is conditioned on the rules being adopted in
accordance with all provisions of the Illinois Administrative
Procedure Act and all rules and procedures of the Joint
Committee on Administrative Rules; any purported rule not so
adopted, for whatever reason, is unauthorized.
(Source: P.A. 100-863, eff. 8-14-18; 101-580, eff. 1-1-20.)
Section 15. The Illinois Insurance Code is amended by
changing Section 356g as follows:
(215 ILCS 5/356g) (from Ch. 73, par. 968g)
Sec. 356g. Mammograms; mastectomies.
(a) Every insurer shall provide in each group or
individual policy, contract, or certificate of insurance
issued or renewed for persons who are residents of this State,

HB4180 Engrossed - 15 - LRB103 34255 MXP 64081 b
coverage for screening by low-dose mammography for all
patients women 35 years of age or older for the presence of
occult breast cancer within the provisions of the policy,
contract, or certificate. The coverage shall be as follows:
(1) A baseline mammogram for patients women 35 to 39
years of age.
(2) An annual mammogram for patients women 40 years
of age or older.
(3) A mammogram at the age and intervals considered
medically necessary by the patient's woman's health care
provider for patients women under 40 years of age and
having a family history of breast cancer, prior personal
history of breast cancer, positive genetic testing, or
other risk factors.
(4) For an individual or group policy of accident and
health insurance or a managed care plan that is amended,
delivered, issued, or renewed on or after January 1, 2020
(the effective date of Public Act 101-580) this amendatory
Act of the 101st General Assembly, a comprehensive
ultrasound screening and MRI of an entire breast or
breasts if a mammogram demonstrates heterogeneous or dense
breast tissue or when medically necessary as determined by
a physician licensed to practice medicine in all of its
branches.
(4.5) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed

HB4180 Engrossed - 16 - LRB103 34255 MXP 64081 b
on or after the effective date of this amendatory Act of
the 103rd General Assembly, molecular breast imaging (MBI)
of an entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches, advanced
practice registered nurse, or physician assistant.
(5) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(6) For an individual or group policy of accident and
health insurance or a managed care plan that is amended,
delivered, issued, or renewed on or after January 1, 2020
(the effective date of Public Act 101-580) this amendatory
Act of the 101st General Assembly, a diagnostic mammogram
when medically necessary, as determined by a physician
licensed to practice medicine in all its branches,
advanced practice registered nurse, or physician
assistant.
A policy subject to this subsection shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26

HB4180 Engrossed - 17 - LRB103 34255 MXP 64081 b
U.S.C. 223).
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with radiation exposure delivery of less than
1 rad per breast for 2 views of an average size breast. The
term also includes digital mammography and includes breast
tomosynthesis. As used in this Section, the term "breast
tomosynthesis" means a radiologic procedure that involves the
acquisition of projection images over the stationary breast to
produce cross-sectional digital three-dimensional images of
the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the

HB4180 Engrossed - 18 - LRB103 34255 MXP 64081 b
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
subsection, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this subsection.
(a-5) Coverage as described by subsection (a) shall be
provided at no cost to the insured and shall not be applied to
an annual or lifetime maximum benefit.
(a-10) When health care services are available through
contracted providers and a person does not comply with plan
provisions specific to the use of contracted providers, the
requirements of subsection (a-5) are not applicable. When a
person does not comply with plan provisions specific to the
use of contracted providers, plan provisions specific to the
use of non-contracted providers must be applied without
distinction for coverage required by this Section and shall be
at least as favorable as for other radiological examinations
covered by the policy or contract.
(b) No policy of accident or health insurance that
provides for the surgical procedure known as a mastectomy
shall be issued, amended, delivered, or renewed in this State

HB4180 Engrossed - 19 - LRB103 34255 MXP 64081 b
unless that coverage also provides for prosthetic devices or
reconstructive surgery incident to the mastectomy. Coverage
for breast reconstruction in connection with a mastectomy
shall include:
(1) reconstruction of the breast upon which the
mastectomy has been performed;
(2) surgery and reconstruction of the other breast to
produce a symmetrical appearance; and
(3) prostheses and treatment for physical
complications at all stages of mastectomy, including
lymphedemas.
Care shall be determined in consultation with the attending
physician and the patient. The offered coverage for prosthetic
devices and reconstructive surgery shall be subject to the
deductible and coinsurance conditions applied to the
mastectomy, and all other terms and conditions applicable to
other benefits. When a mastectomy is performed and there is no
evidence of malignancy then the offered coverage may be
limited to the provision of prosthetic devices and
reconstructive surgery to within 2 years after the date of the
mastectomy. As used in this Section, "mastectomy" means the
removal of all or part of the breast for medically necessary
reasons, as determined by a licensed physician.
Written notice of the availability of coverage under this
Section shall be delivered to the insured upon enrollment and
annually thereafter. An insurer may not deny to an insured

HB4180 Engrossed - 20 - LRB103 34255 MXP 64081 b
eligibility, or continued eligibility, to enroll or to renew
coverage under the terms of the plan solely for the purpose of
avoiding the requirements of this Section. An insurer may not
penalize or reduce or limit the reimbursement of an attending
provider or provide incentives (monetary or otherwise) to an
attending provider to induce the provider to provide care to
an insured in a manner inconsistent with this Section.
(c) Rulemaking authority to implement Public Act 95-1045,
if any, is conditioned on the rules being adopted in
accordance with all provisions of the Illinois Administrative
Procedure Act and all rules and procedures of the Joint
Committee on Administrative Rules; any purported rule not so
adopted, for whatever reason, is unauthorized.
(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
Section 20. The Health Maintenance Organization Act is
amended by changing Sections 4-6.1 and 5-3 as follows:
(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
Sec. 4-6.1. Mammograms; mastectomies.
(a) Every contract or evidence of coverage issued by a
Health Maintenance Organization for persons who are residents
of this State shall contain coverage for screening by low-dose
mammography for all patients women 35 years of age or older for
the presence of occult breast cancer. The coverage shall be as
follows:

HB4180 Engrossed - 21 - LRB103 34255 MXP 64081 b
(1) A baseline mammogram for patients women 35 to 39
years of age.
(2) An annual mammogram for patients women 40 years of
age or older.
(3) A mammogram at the age and intervals considered
medically necessary by the patient's woman's health care
provider for patients women under 40 years of age and
having a family history of breast cancer, prior personal
history of breast cancer, positive genetic testing, or
other risk factors.
(4) For an individual or group policy of accident and
health insurance or a managed care plan that is amended,
delivered, issued, or renewed on or after January 1, 2020
(the effective date of Public Act 101-580) this amendatory
Act of the 101st General Assembly, a comprehensive
ultrasound screening and MRI of an entire breast or
breasts if a mammogram demonstrates heterogeneous or dense
breast tissue or when medically necessary as determined by
a physician licensed to practice medicine in all of its
branches.
(4.5) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after the effective date of this amendatory Act of
the 103rd General Assembly, molecular breast imaging (MBI)
of an entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically

HB4180 Engrossed - 22 - LRB103 34255 MXP 64081 b
necessary as determined by a physician licensed to
practice medicine in all of its branches, advanced
practice registered nurse, or physician assistant.
(5) For an individual or group policy of accident and
health insurance or a managed care plan that is amended,
delivered, issued, or renewed on or after January 1, 2020
(the effective date of Public Act 101-580) this amendatory
Act of the 101st General Assembly, a diagnostic mammogram
when medically necessary, as determined by a physician
licensed to practice medicine in all its branches,
advanced practice registered nurse, or physician
assistant.
A policy subject to this subsection shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a

HB4180 Engrossed - 23 - LRB103 34255 MXP 64081 b
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with radiation exposure delivery of less than
1 rad per breast for 2 views of an average size breast. The
term also includes digital mammography and includes breast
tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
subsection, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42

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U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this subsection.
(a-5) Coverage as described in subsection (a) shall be
provided at no cost to the enrollee and shall not be applied to
an annual or lifetime maximum benefit.
(b) No contract or evidence of coverage issued by a health
maintenance organization that provides for the surgical
procedure known as a mastectomy shall be issued, amended,
delivered, or renewed in this State on or after July 3, 2001
(the effective date of Public Act 92-0048) this amendatory Act
of the 92nd General Assembly unless that coverage also
provides for prosthetic devices or reconstructive surgery
incident to the mastectomy, providing that the mastectomy is
performed after July 3, 2001 the effective date of this
amendatory Act. Coverage for breast reconstruction in
connection with a mastectomy shall include:
(1) reconstruction of the breast upon which the
mastectomy has been performed;
(2) surgery and reconstruction of the other breast to
produce a symmetrical appearance; and
(3) prostheses and treatment for physical
complications at all stages of mastectomy, including
lymphedemas.
Care shall be determined in consultation with the attending
physician and the patient. The offered coverage for prosthetic

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devices and reconstructive surgery shall be subject to the
deductible and coinsurance conditions applied to the
mastectomy and all other terms and conditions applicable to
other benefits. When a mastectomy is performed and there is no
evidence of malignancy, then the offered coverage may be
limited to the provision of prosthetic devices and
reconstructive surgery to within 2 years after the date of the
mastectomy. As used in this Section, "mastectomy" means the
removal of all or part of the breast for medically necessary
reasons, as determined by a licensed physician.
Written notice of the availability of coverage under this
Section shall be delivered to the enrollee upon enrollment and
annually thereafter. A health maintenance organization may not
deny to an enrollee eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the plan solely
for the purpose of avoiding the requirements of this Section.
A health maintenance organization may not penalize or reduce
or limit the reimbursement of an attending provider or provide
incentives (monetary or otherwise) to an attending provider to
induce the provider to provide care to an insured in a manner
inconsistent with this Section.
(c) Rulemaking authority to implement this amendatory Act
of the 95th General Assembly, if any, is conditioned on the
rules being adopted in accordance with all provisions of the
Illinois Administrative Procedure Act and all rules and
procedures of the Joint Committee on Administrative Rules; any

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purported rule not so adopted, for whatever reason, is
unauthorized.
(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
Sec. 5-3. Insurance Code provisions.
(a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 136, 137, 139, 140,
141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 155.49,
355.2, 355.3, 355b, 355c, 356f, 356g, 356g.5-1, 356m, 356q,
356v, 356w, 356x, 356z.2, 356z.3a, 356z.4, 356z.4a, 356z.5,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.20, 356z.21,
356z.22, 356z.23, 356z.24, 356z.25, 356z.26, 356z.28, 356z.29,
356z.30, 356z.30a, 356z.31, 356z.32, 356z.33, 356z.34,
356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 356z.41,
356z.44, 356z.45, 356z.46, 356z.47, 356z.48, 356z.49, 356z.50,
356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.58,
356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.65, 356z.67,
356z.68, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,
368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
subsection (2) of Section 367, and Articles IIA, VIII 1/2,
XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
Illinois Insurance Code.

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(b) For purposes of the Illinois Insurance Code, except
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
Health Maintenance Organizations in the following categories
are deemed to be "domestic companies":
(1) a corporation authorized under the Dental Service
Plan Act or the Voluntary Health Services Plans Act;
(2) a corporation organized under the laws of this
State; or
(3) a corporation organized under the laws of another
state, 30% or more of the enrollees of which are residents
of this State, except a corporation subject to
substantially the same requirements in its state of
organization as is a "domestic company" under Article VIII
1/2 of the Illinois Insurance Code.
(c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
(1) the Director shall give primary consideration to
the continuation of benefits to enrollees and the
financial conditions of the acquired Health Maintenance
Organization after the merger, consolidation, or other
acquisition of control takes effect;
(2)(i) the criteria specified in subsection (1)(b) of
Section 131.8 of the Illinois Insurance Code shall not
apply and (ii) the Director, in making his determination
with respect to the merger, consolidation, or other

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acquisition of control, need not take into account the
effect on competition of the merger, consolidation, or
other acquisition of control;
(3) the Director shall have the power to require the
following information:
(A) certification by an independent actuary of the
adequacy of the reserves of the Health Maintenance
Organization sought to be acquired;
(B) pro forma financial statements reflecting the
combined balance sheets of the acquiring company and
the Health Maintenance Organization sought to be
acquired as of the end of the preceding year and as of
a date 90 days prior to the acquisition, as well as pro
forma financial statements reflecting projected
combined operation for a period of 2 years;
(C) a pro forma business plan detailing an
acquiring party's plans with respect to the operation
of the Health Maintenance Organization sought to be
acquired for a period of not less than 3 years; and
(D) such other information as the Director shall
require.
(d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale by
any health maintenance organization of greater than 10% of its
enrollee population (including, without limitation, the health
maintenance organization's right, title, and interest in and

HB4180 Engrossed - 29 - LRB103 34255 MXP 64081 b
to its health care certificates).
(e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code,
take into account the effect of the management contract or
service agreement on the continuation of benefits to enrollees
and the financial condition of the health maintenance
organization to be managed or serviced, and (ii) need not take
into account the effect of the management contract or service
agreement on competition.
(f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a
Health Maintenance Organization may by contract agree with a
group or other enrollment unit to effect refunds or charge
additional premiums under the following terms and conditions:
(i) the amount of, and other terms and conditions with
respect to, the refund or additional premium are set forth
in the group or enrollment unit contract agreed in advance
of the period for which a refund is to be paid or
additional premium is to be charged (which period shall
not be less than one year); and
(ii) the amount of the refund or additional premium
shall not exceed 20% of the Health Maintenance

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Organization's profitable or unprofitable experience with
respect to the group or other enrollment unit for the
period (and, for purposes of a refund or additional
premium, the profitable or unprofitable experience shall
be calculated taking into account a pro rata share of the
Health Maintenance Organization's administrative and
marketing expenses, but shall not include any refund to be
made or additional premium to be paid pursuant to this
subsection (f)). The Health Maintenance Organization and
the group or enrollment unit may agree that the profitable
or unprofitable experience may be calculated taking into
account the refund period and the immediately preceding 2
plan years.
The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and
the resulting additional premium to be paid by the group or
enrollment unit.
In no event shall the Illinois Health Maintenance

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Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay any
refund authorized under this Section.
(g) Rulemaking authority to implement Public Act 95-1045,
if any, is conditioned on the rules being adopted in
accordance with all provisions of the Illinois Administrative
Procedure Act and all rules and procedures of the Joint
Committee on Administrative Rules; any purported rule not so
adopted, for whatever reason, is unauthorized.
(Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
eff. 1-1-24; 103-551, eff. 8-11-23; revised 8-29-23.)
Section 25. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
(305 ILCS 5/5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate

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of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed
to practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,

HB4180 Engrossed - 33 - LRB103 34255 MXP 64081 b
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; (16.5) services performed by
a chiropractic physician licensed under the Medical Practice
Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered

HB4180 Engrossed - 34 - LRB103 34255 MXP 64081 b
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of

HB4180 Engrossed - 35 - LRB103 34255 MXP 64081 b
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL

HB4180 Engrossed - 36 - LRB103 34255 MXP 64081 b
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever
the person may select.
On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.

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On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare
and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office

HB4180 Engrossed - 38 - LRB103 34255 MXP 64081 b
delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements
for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the
State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school
district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the

HB4180 Engrossed - 39 - LRB103 34255 MXP 64081 b
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39
years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care
provider for individuals under 40 years of age and having
a family history of breast cancer, prior personal history
of breast cancer, positive genetic testing, or other risk
factors.
(D) A comprehensive ultrasound screening and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in

HB4180 Engrossed - 40 - LRB103 34255 MXP 64081 b
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
(G) Molecular breast imaging (MBI) and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches, advanced
practice registered nurse, or physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.

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"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this

HB4180 Engrossed - 42 - LRB103 34255 MXP 64081 b
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after
January 1, 2023 (the effective date of Public Act 102-1018),
breast tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare

HB4180 Engrossed - 43 - LRB103 34255 MXP 64081 b
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including radiologists that are trained in all forms
of FDA approved breast imaging technologies, breast surgeons,
reconstructive breast surgeons, oncologists, and primary care
providers to establish quality standards for breast cancer
treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.

HB4180 Engrossed - 44 - LRB103 34255 MXP 64081 b
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one

HB4180 Engrossed - 45 - LRB103 34255 MXP 64081 b
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all
persons between the ages of 9 and 45. Subject to federal
approval, the Department shall provide coverage and
reimbursement for a human papillomavirus (HPV) vaccine for
persons of the age of 46 and above who have been diagnosed with
cervical dysplasia with a high risk of recurrence or
progression. The Department shall disallow any
preauthorization requirements for the administration of the
human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed

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hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations

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governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients

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in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of

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choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of

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the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013

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(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,

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associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon the category of risk
of the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on

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the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:

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(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required
prescreening information, new admissions with associated

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admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security

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numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or

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rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement

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wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping

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costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of the same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to

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37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for

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medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on

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Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of

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alcohol dependence or treatment of opioid dependence shall be
covered under both fee-for-service fee for service and managed
care medical assistance programs for persons who are otherwise
eligible for medical assistance under this Article and shall
not be subject to any (1) utilization control, other than
those established under the American Society of Addiction
Medicine patient placement criteria, (2) prior authorization
mandate, or (3) lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited
to, naloxone hydrochloride or any other similarly acting drug
approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that

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are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date
of Public Act 102-665), the Department shall seek federal
approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment

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electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
Notwithstanding any other provision of this Code,
community-based pediatric palliative care from a trained
interdisciplinary team shall be covered under the medical
assistance program as provided in Section 15 of the Pediatric
Palliative Care Act.
Notwithstanding any other provision of this Code, within
12 months after June 2, 2022 (the effective date of Public Act
102-1037) and subject to federal approval, acupuncture
services performed by an acupuncturist licensed under the
Acupuncture Practice Act who is acting within the scope of his
or her license shall be covered under the medical assistance
program. The Department shall apply for any federal waiver or
State Plan amendment, if required, to implement this
paragraph. The Department may adopt any rules, including
standards and criteria, necessary to implement this paragraph.
Notwithstanding any other provision of this Code, the
medical assistance program shall, subject to appropriation and

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federal approval, reimburse hospitals for costs associated
with a newborn screening test for the presence of
metachromatic leukodystrophy, as required under the Newborn
Metabolic Screening Act, at a rate not less than the fee
charged by the Department of Public Health. The Department
shall seek federal approval before the implementation of the
newborn screening test fees by the Department of Public
Health.
Notwithstanding any other provision of this Code,
beginning on January 1, 2024, subject to federal approval,
cognitive assessment and care planning services provided to a
person who experiences signs or symptoms of cognitive
impairment, as defined by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Code,
medically necessary reconstructive services that are intended
to restore physical appearance shall be covered under the
medical assistance program for persons who are otherwise
eligible for medical assistance under this Article. As used in
this paragraph, "reconstructive services" means treatments
performed on structures of the body damaged by trauma to
restore physical appearance.
(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article

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55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1-1-24; revised 12-15-23.)