Bill Amendment: IL SB1909 | 2019-2020 | 101st General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: ALZHEIMER-BEHAVIOR RISK FACTOR

Status: 2019-12-13 - Public Act . . . . . . . . . 101-0609 [SB1909 Detail]

Download: Illinois-2019-SB1909-Senate_Amendment_004.html

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Sen. Cristina Castro

Filed: 4/5/2019

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AMENDMENT TO SENATE BILL 1909
AMENDMENT NO. ______. Amend Senate Bill 1909, AS AMENDED,
by replacing everything after the enacting clause with the
following:
"Section 1. This Act may be referred to as the Improving
Health Care for Pregnant and Postpartum Individuals Act.
Section 5. The State Employees Group Insurance Act of 1971
is amended by changing Section 6.11 as follows:
(5 ILCS 375/6.11)
(Text of Section before amendment by P.A. 100-1170)
Sec. 6.11. Required health benefits; Illinois Insurance
Code requirements. The program of health benefits shall provide
the post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t of
the Illinois Insurance Code. The program of health benefits

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shall provide the coverage required under Sections 356g,
356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and
356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code.
The program of health benefits must comply with Sections
155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 of the
Illinois Insurance Code. The Department of Insurance shall
enforce the requirements of this Section.
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. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
1-8-19.)
(Text of Section after amendment by P.A. 100-1170)
Sec. 6.11. Required health benefits; Illinois Insurance
Code requirements. The program of health benefits shall provide
the post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t of
the Illinois Insurance Code. The program of health benefits

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shall provide the coverage required under Sections 356g,
356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29,
and 356z.32, and 356z.33 of the Illinois Insurance Code. The
program of health benefits must comply with Sections 155.22a,
155.37, 355b, 356z.19, 370c, and 370c.1 of the Illinois
Insurance Code. The Department of Insurance shall enforce the
requirements of this Section with respect to Sections 370c and
370c.1 of the Illinois Insurance Code; all other requirements
of this Section shall be enforced by the Department of Central
Management Services.
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. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19;
100-1170, eff. 6-1-19.)
Section 10. The Department of Human Services Act is amended
by adding Sections 10-23 and 10-24 as follows:

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(20 ILCS 1305/10-23 new)
Sec. 10-23. High-risk pregnant or postpartum women. The
Department shall expand and update its maternal child health
programs to serve any pregnant or postpartum woman identified
as high-risk by her primary care provider or hospital according
to standards developed by the Department of Public Health under
Section 3 of the Developmental Disability Prevention Act. The
services shall be provided by registered nurses, licensed
social workers, or other staff with behavioral health or
medical training, as approved by the Department. The persons
providing the services may collaborate with other providers,
including, but not limited to, obstetricians, gynecologists,
or pediatricians, when providing services to a patient.
(20 ILCS 1305/10-24 new)
Sec. 10-24. Nurse-Family Partnership Pilot Program.
Subject to the availability of funds provided for this purpose
by public or private sources, the Department may, in its
discretion, establish an evidence-based, voluntary, nurse home
visitation program that improves the health and well-being of
low-income, first-time pregnant women and their children. The
program shall be known as the Nurse-Family Partnership Pilot
Program and shall include, but not be limited to, the following
components:
(1) Eligibility criteria. Program participants must be
first-time pregnant women who have yet to reach the 28th

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week of pregnancy and who are eligible for medical
assistance under Article V of the Illinois Public Aid Code.
(2) Maternal health education. Registered nurses shall
make home visits to program participants and shall provide
education, support, and guidance regarding pregnancy and
maternal health, child health and development, parenting,
the mother's life course development, and instruction on
how to identify and use family and community supports.
(3) Pre-natal and post-natal care. Home visits to
program participants shall begin before their 28th week of
pregnancy and shall continue on a weekly or biweekly basis
until their children reach the age of 2.
Section 15. The Department of Public Health Powers and
Duties Law of the Civil Administrative Code of Illinois is
amended by adding Section 2310-455 as follows:
(20 ILCS 2310/2310-455 new)
Sec. 2310-455. High Risk Infant Follow-up. The Department,
in collaboration with the Department of Human Services, the
Department of Healthcare and Family Services, and other key
providers of maternal child health services, shall revise or
add to the rules of the Maternal and Child Health Services Code
(77 Ill. Adm. Code 630) that govern the High Risk Infant
Follow-up, using current scientific and national and State
outcomes data, to expand existing services to improve both

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maternal and infant outcomes overall and to reduce racial
disparities in outcomes and services provided. The rules shall
be revised or adopted on or before June 1, 2021.
Section 20. The Counties Code is amended by changing
Section 5-1069.3 as follows:
(55 ILCS 5/5-1069.3)
Sec. 5-1069.3. Required health benefits. If a county,
including a home rule county, is a self-insurer for purposes of
providing health insurance coverage for its employees, the
coverage shall include coverage for the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and 356z.29,
356z.32, and 356z.33 of the Illinois Insurance Code. The
coverage shall comply with Sections 155.22a, 355b, 356z.19, and
370c of the Illinois Insurance Code. The Department of
Insurance shall enforce the requirements of this Section. The
requirement that health benefits be covered as provided in this
Section 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. A home rule county
to which this Section applies must comply with every provision

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of this Section.
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. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
10-3-18.)
Section 25. The Illinois Municipal Code is amended by
changing Section 10-4-2.3 as follows:
(65 ILCS 5/10-4-2.3)
Sec. 10-4-2.3. Required health benefits. If a
municipality, including a home rule municipality, is a
self-insurer for purposes of providing health insurance
coverage for its employees, the coverage shall include coverage
for the post-mastectomy care benefits required to be covered by
a policy of accident and health insurance under Section 356t
and the coverage required under Sections 356g, 356g.5,
356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25,
and 356z.26, and 356z.29, 356z.32, and 356z.33 of the Illinois

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Insurance Code. The coverage shall comply with Sections
155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
Code. The Department of Insurance shall enforce the
requirements of this Section. The requirement that health
benefits be covered as provided in this 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. A home rule municipality to which this Section
applies must comply with every provision of this Section.
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. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
10-4-18.)
Section 30. The School Code is amended by changing Section
10-22.3f as follows:
(105 ILCS 5/10-22.3f)
Sec. 10-22.3f. Required health benefits. Insurance
protection and benefits for employees shall provide the

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post-mastectomy care benefits required to be covered by a
policy of accident and health insurance under Section 356t and
the coverage required under Sections 356g, 356g.5, 356g.5-1,
356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
356z.13, 356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and
356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code.
Insurance policies shall comply with Section 356z.19 of the
Illinois Insurance Code. The coverage shall comply with
Sections 155.22a, 355b, and 370c of the Illinois Insurance
Code. The Department of Insurance shall enforce the
requirements of this Section.
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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
1-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.)
Section 35. The Illinois Insurance Code is amended by
adding Sections 356z.4a and 356z.33 as follows:
(215 ILCS 5/356z.4a new)
Sec. 356z.4a. Billing for long-acting reversible

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contraceptives.
(a) "Long-acting reversible contraceptive device" means
any intrauterine device or contraceptive implant.
(b) Any group health insurance policy, individual health
policy, group policy of accident and health insurance, group
health benefit plan, or qualified health plan that is offered
through the health insurance marketplace, a small employer
group health plan, or a large employer group health plan that
is amended, delivered, issued, or renewed on or after the
effective date of this amendatory Act of the 101st General
Assembly shall allow hospitals separate reimbursement for a
long-acting reversible contraceptive device provided
immediately postpartum in the inpatient hospital setting
before hospital discharge. The payment shall be made in
addition to a bundled or Diagnostic Related Group reimbursement
for labor and delivery.
(215 ILCS 5/356z.33 new)
Sec. 356z.33. Pregnancy and postpartum coverage.
(a) A group health insurance policy, individual health
policy, group policy of accident and health insurance, group
health benefit plan, qualified health plan that is offered
through the health insurance marketplace, small employer group
health plan, or large employer group health plan that is
amended, delivered, issued, or renewed on or after the
effective date of this amendatory Act of the 101st General

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Assembly shall provide coverage for medically necessary
treatment for postpartum complications, including, but not
limited to, infection, depression, and hemorrhaging, up to one
year after the woman has given birth to a child as set forth in
this Section and consistent with other Sections of this Code,
including, but not limited to, Sections 370c and 370c.1. The
coverage under this Section shall be subject to other general
exclusions, limitations, and financial requirements of the
policy, including coordination of benefits, participating
provider requirements, and utilization review of health care
services, including review of medical necessity, case
management, experimental and investigational treatments,
managed care provisions, and other terms and conditions.
(b) A group health insurance policy, individual health
policy, group policy of accident and health insurance, group
health benefit plan, qualified health plan that is offered
through the health insurance marketplace, small employer group
health plan, or large employer group health plan that is
amended, delivered, issued, or renewed on or after the
effective date of this amendatory Act of the 101st General
Assembly shall provide coverage for medically necessary
treatment of mental, emotional, nervous, or substance use
disorder or conditions at in-network facilities for a pregnant
or postpartum woman up to one year after giving birth to a
child consistent with the requirements set forth in this
Section and in Sections 370c and 370c.1 of this Code. The

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services for the treatment of mental, emotional, nervous, or
substance use disorder or condition shall be prescribed or
ordered by a licensed physician, licensed psychologist,
licensed psychiatrist, or licensed advanced practice
registered nurse and provided by licensed health care
professionals or licensed or certified mental, emotional,
nervous, or substance use disorder or conditions providers in
licensed, certified, or otherwise State-approved facilities.
As used in this subsection (b), "provider" includes
licensed physicians, licensed psychologists, licensed
psychiatrists, licensed advanced practice registered nurses,
and licensed and certified mental, emotional, nervous, and
substance use disorder and conditions providers.
Benefits under this subsection (b) shall be as follows:
(1) The benefits provided for inpatient and outpatient
services for the treatment of mental, emotional, nervous,
or substance use disorder or conditions related to
pregnancy or postpartum complications shall be provided
when determined to be medically necessary consistent with
the requirements of Sections 370c and 370c.1 of this Code.
The facility or provider shall notify the insurer of both
the admission and the initial treatment plan within 48
hours after admission or initiation of treatment. Nothing
shall prevent an insurer from applying concurrent and
post-service utilization review of health care services,
including review of medical necessity, case management,

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experimental and investigational treatments, managed care
provisions, and other terms and conditions of the insurance
policy.
(2) The benefits for the first 48 hours of initiation
of services for an inpatient admission,
detoxification/withdrawal management program, or a partial
hospitalization admission for the treatment of mental,
emotional, nervous, or substance use disorder or
conditions related to pregnancy or postpartum
complications shall be provided without post-service or
concurrent review of medical necessity, as the medical
necessity for the first 48 hours of such services shall be
determined solely by the covered pregnant or postpartum
woman's provider. Nothing shall prevent an insurer from
applying concurrent and post-service utilization review,
including the review of medical necessity, case
management, experimental and investigational treatments,
managed care provisions, and other terms and conditions of
the insurance policy of any inpatient admission,
detoxification/withdrawal management program admission, or
a partial hospitalization admission services for the
treatment of mental emotional, nervous, or substance use
disorder or conditions related to pregnancy or postpartum
complications received 48 hours after the initiation of
such services. If an insurer determines that the services
are no longer medically necessary, then the covered person

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shall have the right to external review pursuant to the
requirements of the Health Carrier External Review Act.
(3) If an insurer determines that continued inpatient
care, detoxification/withdrawal management, partial
hospitalization, intensive outpatient treatment, or
outpatient treatment in a facility is no longer medically
necessary, the insurer shall, within 24 hours, provide
written notice to the covered pregnant or postpartum woman
and the covered pregnant or postpartum woman's provider of
its decision and the right to file an expedited internal
appeal of the determination. The insurer shall review and
make a determination with respect to the internal appeal
within 24 hours and communicate such determination to the
covered pregnant or postpartum woman and the covered
pregnant or postpartum woman's provider. If the
determination is to uphold the denial, the covered pregnant
or postpartum woman and the covered pregnant or postpartum
woman's provider have the right to file an expedited
external appeal. An independent utilization review
organization shall make a determination within 72 hours. If
the insurer's determination is upheld and it is determined
continued inpatient care, detoxification/withdrawal
management, partial hospitalization, intensive outpatient
treatment, or outpatient treatment is not medically
necessary, the insurer shall remain responsible to provide
benefits for the inpatient care, detoxification/withdrawal

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management, partial hospitalization, intensive outpatient
treatment, or outpatient treatment through the day
following the date the determination is made and the
covered pregnant or postpartum woman shall only be
responsible for any applicable copayment, deductible, and
coinsurance for the stay through that date as applicable
under the policy. The covered pregnant or postpartum woman
shall not be discharged or released from the inpatient
facility, detoxification/withdrawal management, partial
hospitalization, intensive outpatient treatment, or
outpatient treatment until all internal appeals and
independent utilization review organization appeals are
exhausted. A decision to reverse an adverse determination
shall comply with the Health Carrier External Review Act.
(4) Except as otherwise stated in this subsection (b),
the benefits and cost-sharing shall be provided to the same
extent as for any other medical condition covered under the
policy.
(5) The benefits required by this subsection (b) are to
be provided to all covered pregnant or postpartum woman
with a diagnosis of mental, emotional, nervous, or
substance use disorder or conditions. The presence of
additional related or unrelated diagnoses shall not be a
basis to reduce or deny the benefits required by this
subsection (b).
(c) A group health insurance policy, individual health

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policy, group policy of accident and health insurance, group
health benefit plan, qualified health plan that is offered
through the health insurance marketplace, small employer group
health plan, or large employer group health plan that is
amended, delivered, issued, executed, or renewed in this State
or approved for issuance or renewal in this State on or after
the effective date of this amendatory Act of the 101st General
Assembly shall provide coverage for case management and
outreach for a postpartum woman that had a high-risk pregnancy.
The coverage under this subsection (c) shall take into
consideration the cultural differences of the covered
postpartum woman in case coordination. As used in this
subsection (c), "high-risk pregnancy" means a pregnancy in
which the mother or baby is at increased risk for poor health
or complications during pregnancy or childbirth.
Section 40. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
(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, 355.2, 355.3,
355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,

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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.21,
356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33,
364, 364.01, 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, and XXVI of the Illinois Insurance Code.
(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

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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
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

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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 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:

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(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
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

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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
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. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff.
8-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
10-4-18.)
Section 45. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
(215 ILCS 165/10) (from Ch. 32, par. 604)

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Sec. 10. Application of Insurance Code provisions. Health
services plan corporations and all persons interested therein
or dealing therewith shall be subject to the provisions of
Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
356z.32, 356z.33, 364.01, 367.2, 368a, 401, 401.1, 402, 403,
403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
Section 367 of the Illinois Insurance Code.
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. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
1-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.)
Section 50. The Illinois Public Aid Code is amended by
changing Sections 5-2, 5-5, and 5-5.24 and by adding Section
5-5.27 as follows:

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(305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
Sec. 5-2. Classes of Persons Eligible.
Medical assistance under this Article shall be available to
any of the following classes of persons in respect to whom a
plan for coverage has been submitted to the Governor by the
Illinois Department and approved by him. If changes made in
this Section 5-2 require federal approval, they shall not take
effect until such approval has been received:
1. Recipients of basic maintenance grants under
Articles III and IV.
2. Beginning January 1, 2014, persons otherwise
eligible for basic maintenance under Article III,
excluding any eligibility requirements that are
inconsistent with any federal law or federal regulation, as
interpreted by the U.S. Department of Health and Human
Services, but who fail to qualify thereunder on the basis
of need, and who have insufficient income and resources to
meet the costs of necessary medical care, including but not
limited to the following:
(a) All persons otherwise eligible for basic
maintenance under Article III but who fail to qualify
under that Article on the basis of need and who meet
either of the following requirements:
(i) their income, as determined by the
Illinois Department in accordance with any federal
requirements, is equal to or less than 100% of the

10100SB1909sam004 - 24 - LRB101 09278 CPF 59162 a
federal poverty level; or
(ii) their income, after the deduction of
costs incurred for medical care and for other types
of remedial care, is equal to or less than 100% of
the federal poverty level.
(b) (Blank).
3. (Blank).
4. Persons not eligible under any of the preceding
paragraphs who fall sick, are injured, or die, not having
sufficient money, property or other resources to meet the
costs of necessary medical care or funeral and burial
expenses.
5.(a) Women during pregnancy and during the 12-month
60-day period beginning on the last day of the pregnancy,
together with their infants, whose income is at or below
200% of the federal poverty level. Until September 30,
2019, or sooner if the maintenance of effort requirements
under the Patient Protection and Affordable Care Act are
eliminated or may be waived before then, women during
pregnancy and during the 12-month 60-day period beginning
on the last day of the pregnancy, whose countable monthly
income, after the deduction of costs incurred for medical
care and for other types of remedial care as specified in
administrative rule, is equal to or less than the Medical
Assistance-No Grant(C) (MANG(C)) Income Standard in effect
on April 1, 2013 as set forth in administrative rule.

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(b) The plan for coverage shall provide ambulatory
prenatal care to pregnant women during a presumptive
eligibility period and establish an income eligibility
standard that is equal to 200% of the federal poverty
level, provided that costs incurred for medical care are
not taken into account in determining such income
eligibility.
(c) The Illinois Department may conduct a
demonstration in at least one county that will provide
medical assistance to pregnant women, together with their
infants and children up to one year of age, where the
income eligibility standard is set up to 185% of the
nonfarm income official poverty line, as defined by the
federal Office of Management and Budget. The Illinois
Department shall seek and obtain necessary authorization
provided under federal law to implement such a
demonstration. Such demonstration may establish resource
standards that are not more restrictive than those
established under Article IV of this Code.
6. (a) Children younger than age 19 when countable
income is at or below 133% of the federal poverty level.
Until September 30, 2019, or sooner if the maintenance of
effort requirements under the Patient Protection and
Affordable Care Act are eliminated or may be waived before
then, children younger than age 19 whose countable monthly
income, after the deduction of costs incurred for medical

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care and for other types of remedial care as specified in
administrative rule, is equal to or less than the Medical
Assistance-No Grant(C) (MANG(C)) Income Standard in effect
on April 1, 2013 as set forth in administrative rule.
(b) Children and youth who are under temporary custody
or guardianship of the Department of Children and Family
Services or who receive financial assistance in support of
an adoption or guardianship placement from the Department
of Children and Family Services.
7. (Blank).
8. As required under federal law, persons who are
eligible for Transitional Medical Assistance as a result of
an increase in earnings or child or spousal support
received. The plan for coverage for this class of persons
shall:
(a) extend the medical assistance coverage to the
extent required by federal law; and
(b) offer persons who have initially received 6
months of the coverage provided in paragraph (a) above,
the option of receiving an additional 6 months of
coverage, subject to the following:
(i) such coverage shall be pursuant to
provisions of the federal Social Security Act;
(ii) such coverage shall include all services
covered under Illinois' State Medicaid Plan;
(iii) no premium shall be charged for such

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coverage; and
(iv) such coverage shall be suspended in the
event of a person's failure without good cause to
file in a timely fashion reports required for this
coverage under the Social Security Act and
coverage shall be reinstated upon the filing of
such reports if the person remains otherwise
eligible.
9. Persons with acquired immunodeficiency syndrome
(AIDS) or with AIDS-related conditions with respect to whom
there has been a determination that but for home or
community-based services such individuals would require
the level of care provided in an inpatient hospital,
skilled nursing facility or intermediate care facility the
cost of which is reimbursed under this Article. Assistance
shall be provided to such persons to the maximum extent
permitted under Title XIX of the Federal Social Security
Act.
10. Participants in the long-term care insurance
partnership program established under the Illinois
Long-Term Care Partnership Program Act who meet the
qualifications for protection of resources described in
Section 15 of that Act.
11. Persons with disabilities who are employed and
eligible for Medicaid, pursuant to Section
1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,

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subject to federal approval, persons with a medically
improved disability who are employed and eligible for
Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
the Social Security Act, as provided by the Illinois
Department by rule. In establishing eligibility standards
under this paragraph 11, the Department shall, subject to
federal approval:
(a) set the income eligibility standard at not
lower than 350% of the federal poverty level;
(b) exempt retirement accounts that the person
cannot access without penalty before the age of 59 1/2,
and medical savings accounts established pursuant to
26 U.S.C. 220;
(c) allow non-exempt assets up to $25,000 as to
those assets accumulated during periods of eligibility
under this paragraph 11; and
(d) continue to apply subparagraphs (b) and (c) in
determining the eligibility of the person under this
Article even if the person loses eligibility under this
paragraph 11.
12. Subject to federal approval, persons who are
eligible for medical assistance coverage under applicable
provisions of the federal Social Security Act and the
federal Breast and Cervical Cancer Prevention and
Treatment Act of 2000. Those eligible persons are defined
to include, but not be limited to, the following persons:

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(1) persons who have been screened for breast or
cervical cancer under the U.S. Centers for Disease
Control and Prevention Breast and Cervical Cancer
Program established under Title XV of the federal
Public Health Services Act in accordance with the
requirements of Section 1504 of that Act as
administered by the Illinois Department of Public
Health; and
(2) persons whose screenings under the above
program were funded in whole or in part by funds
appropriated to the Illinois Department of Public
Health for breast or cervical cancer screening.
"Medical assistance" under this paragraph 12 shall be
identical to the benefits provided under the State's
approved plan under Title XIX of the Social Security Act.
The Department must request federal approval of the
coverage under this paragraph 12 within 30 days after the
effective date of this amendatory Act of the 92nd General
Assembly.
In addition to the persons who are eligible for medical
assistance pursuant to subparagraphs (1) and (2) of this
paragraph 12, and to be paid from funds appropriated to the
Department for its medical programs, any uninsured person
as defined by the Department in rules residing in Illinois
who is younger than 65 years of age, who has been screened
for breast and cervical cancer in accordance with standards

10100SB1909sam004 - 30 - LRB101 09278 CPF 59162 a
and procedures adopted by the Department of Public Health
for screening, and who is referred to the Department by the
Department of Public Health as being in need of treatment
for breast or cervical cancer is eligible for medical
assistance benefits that are consistent with the benefits
provided to those persons described in subparagraphs (1)
and (2). Medical assistance coverage for the persons who
are eligible under the preceding sentence is not dependent
on federal approval, but federal moneys may be used to pay
for services provided under that coverage upon federal
approval.
13. Subject to appropriation and to federal approval,
persons living with HIV/AIDS who are not otherwise eligible
under this Article and who qualify for services covered
under Section 5-5.04 as provided by the Illinois Department
by rule.
14. Subject to the availability of funds for this
purpose, the Department may provide coverage under this
Article to persons who reside in Illinois who are not
eligible under any of the preceding paragraphs and who meet
the income guidelines of paragraph 2(a) of this Section and
(i) have an application for asylum pending before the
federal Department of Homeland Security or on appeal before
a court of competent jurisdiction and are represented
either by counsel or by an advocate accredited by the
federal Department of Homeland Security and employed by a

10100SB1909sam004 - 31 - LRB101 09278 CPF 59162 a
not-for-profit organization in regard to that application
or appeal, or (ii) are receiving services through a
federally funded torture treatment center. Medical
coverage under this paragraph 14 may be provided for up to
24 continuous months from the initial eligibility date so
long as an individual continues to satisfy the criteria of
this paragraph 14. If an individual has an appeal pending
regarding an application for asylum before the Department
of Homeland Security, eligibility under this paragraph 14
may be extended until a final decision is rendered on the
appeal. The Department may adopt rules governing the
implementation of this paragraph 14.
15. Family Care Eligibility.
(a) On and after July 1, 2012, a parent or other
caretaker relative who is 19 years of age or older when
countable income is at or below 133% of the federal
poverty level. A person may not spend down to become
eligible under this paragraph 15.
(b) Eligibility shall be reviewed annually.
(c) (Blank).
(d) (Blank).
(e) (Blank).
(f) (Blank).
(g) (Blank).
(h) (Blank).
(i) Following termination of an individual's

10100SB1909sam004 - 32 - LRB101 09278 CPF 59162 a
coverage under this paragraph 15, the individual must
be determined eligible before the person can be
re-enrolled.
16. Subject to appropriation, uninsured persons who
are not otherwise eligible under this Section who have been
certified and referred by the Department of Public Health
as having been screened and found to need diagnostic
evaluation or treatment, or both diagnostic evaluation and
treatment, for prostate or testicular cancer. For the
purposes of this paragraph 16, uninsured persons are those
who do not have creditable coverage, as defined under the
Health Insurance Portability and Accountability Act, or
have otherwise exhausted any insurance benefits they may
have had, for prostate or testicular cancer diagnostic
evaluation or treatment, or both diagnostic evaluation and
treatment. To be eligible, a person must furnish a Social
Security number. A person's assets are exempt from
consideration in determining eligibility under this
paragraph 16. Such persons shall be eligible for medical
assistance under this paragraph 16 for so long as they need
treatment for the cancer. A person shall be considered to
need treatment if, in the opinion of the person's treating
physician, the person requires therapy directed toward
cure or palliation of prostate or testicular cancer,
including recurrent metastatic cancer that is a known or
presumed complication of prostate or testicular cancer and

10100SB1909sam004 - 33 - LRB101 09278 CPF 59162 a
complications resulting from the treatment modalities
themselves. Persons who require only routine monitoring
services are not considered to need treatment. "Medical
assistance" under this paragraph 16 shall be identical to
the benefits provided under the State's approved plan under
Title XIX of the Social Security Act. Notwithstanding any
other provision of law, the Department (i) does not have a
claim against the estate of a deceased recipient of
services under this paragraph 16 and (ii) does not have a
lien against any homestead property or other legal or
equitable real property interest owned by a recipient of
services under this paragraph 16.
17. Persons who, pursuant to a waiver approved by the
Secretary of the U.S. Department of Health and Human
Services, are eligible for medical assistance under Title
XIX or XXI of the federal Social Security Act.
Notwithstanding any other provision of this Code and
consistent with the terms of the approved waiver, the
Illinois Department, may by rule:
(a) Limit the geographic areas in which the waiver
program operates.
(b) Determine the scope, quantity, duration, and
quality, and the rate and method of reimbursement, of
the medical services to be provided, which may differ
from those for other classes of persons eligible for
assistance under this Article.

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(c) Restrict the persons' freedom in choice of
providers.
18. Beginning January 1, 2014, persons aged 19 or
older, but younger than 65, who are not otherwise eligible
for medical assistance under this Section 5-2, who qualify
for medical assistance pursuant to 42 U.S.C.
1396a(a)(10)(A)(i)(VIII) and applicable federal
regulations, and who have income at or below 133% of the
federal poverty level plus 5% for the applicable family
size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
applicable federal regulations. Persons eligible for
medical assistance under this paragraph 18 shall receive
coverage for the Health Benefits Service Package as that
term is defined in subsection (m) of Section 5-1.1 of this
Code. If Illinois' federal medical assistance percentage
(FMAP) is reduced below 90% for persons eligible for
medical assistance under this paragraph 18, eligibility
under this paragraph 18 shall cease no later than the end
of the third month following the month in which the
reduction in FMAP takes effect.
19. Beginning January 1, 2014, as required under 42
U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
and younger than age 26 who are not otherwise eligible for
medical assistance under paragraphs (1) through (17) of
this Section who (i) were in foster care under the
responsibility of the State on the date of attaining age 18

10100SB1909sam004 - 35 - LRB101 09278 CPF 59162 a
or on the date of attaining age 21 when a court has
continued wardship for good cause as provided in Section
2-31 of the Juvenile Court Act of 1987 and (ii) received
medical assistance under the Illinois Title XIX State Plan
or waiver of such plan while in foster care.
20. Beginning January 1, 2018, persons who are
foreign-born victims of human trafficking, torture, or
other serious crimes as defined in Section 2-19 of this
Code and their derivative family members if such persons:
(i) reside in Illinois; (ii) are not eligible under any of
the preceding paragraphs; (iii) meet the income guidelines
of subparagraph (a) of paragraph 2; and (iv) meet the
nonfinancial eligibility requirements of Sections 16-2,
16-3, and 16-5 of this Code. The Department may extend
medical assistance for persons who are foreign-born
victims of human trafficking, torture, or other serious
crimes whose medical assistance would be terminated
pursuant to subsection (b) of Section 16-5 if the
Department determines that the person, during the year of
initial eligibility (1) experienced a health crisis, (2)
has been unable, after reasonable attempts, to obtain
necessary information from a third party, or (3) has other
extenuating circumstances that prevented the person from
completing his or her application for status. The
Department may adopt any rules necessary to implement the
provisions of this paragraph.

10100SB1909sam004 - 36 - LRB101 09278 CPF 59162 a
In implementing the provisions of Public Act 96-20, the
Department is authorized to adopt only those rules necessary,
including emergency rules. Nothing in Public Act 96-20 permits
the Department to adopt rules or issue a decision that expands
eligibility for the FamilyCare Program to a person whose income
exceeds 185% of the Federal Poverty Level as determined from
time to time by the U.S. Department of Health and Human
Services, unless the Department is provided with express
statutory authority.
The eligibility of any such person for medical assistance
under this Article is not affected by the payment of any grant
under the Senior Citizens and Persons with Disabilities
Property Tax Relief Act or any distributions or items of income
described under subparagraph (X) of paragraph (2) of subsection
(a) of Section 203 of the Illinois Income Tax Act.
The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for medical
assistance, which shall at a minimum equal the amounts to be
disregarded under the Federal Supplemental Security Income
Program. The amount of assets of a single person to be
disregarded shall not be less than $2,000, and the amount of
assets of a married couple to be disregarded shall not be less
than $3,000.
To the extent permitted under federal law, any person found
guilty of a second violation of Article VIIIA shall be
ineligible for medical assistance under this Article, as

10100SB1909sam004 - 37 - LRB101 09278 CPF 59162 a
provided in Section 8A-8.
The eligibility of any person for medical assistance under
this Article shall not be affected by the receipt by the person
of donations or benefits from fundraisers held for the person
in cases of serious illness, as long as neither the person nor
members of the person's family have actual control over the
donations or benefits or the disbursement of the donations or
benefits.
Notwithstanding any other provision of this Code, if the
United States Supreme Court holds Title II, Subtitle A, Section
2001(a) of Public Law 111-148 to be unconstitutional, or if a
holding of Public Law 111-148 makes Medicaid eligibility
allowed under Section 2001(a) inoperable, the State or a unit
of local government shall be prohibited from enrolling
individuals in the Medical Assistance Program as the result of
federal approval of a State Medicaid waiver on or after the
effective date of this amendatory Act of the 97th General
Assembly, and any individuals enrolled in the Medical
Assistance Program pursuant to eligibility permitted as a
result of such a State Medicaid waiver shall become immediately
ineligible.
Notwithstanding any other provision of this Code, if an Act
of Congress that becomes a Public Law eliminates Section
2001(a) of Public Law 111-148, the State or a unit of local
government shall be prohibited from enrolling individuals in
the Medical Assistance Program as the result of federal

10100SB1909sam004 - 38 - LRB101 09278 CPF 59162 a
approval of a State Medicaid waiver on or after the effective
date of this amendatory Act of the 97th General Assembly, and
any individuals enrolled in the Medical Assistance Program
pursuant to eligibility permitted as a result of such a State
Medicaid waiver shall become immediately ineligible.
Effective October 1, 2013, the determination of
eligibility of persons who qualify under paragraphs 5, 6, 8,
15, 17, and 18 of this Section shall comply with the
requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
regulations.
The Department of Healthcare and Family Services, the
Department of Human Services, and the Illinois health insurance
marketplace shall work cooperatively to assist persons who
would otherwise lose health benefits as a result of changes
made under this amendatory Act of the 98th General Assembly to
transition to other health insurance coverage.
(Source: P.A. 98-104, eff. 7-22-13; 98-463, eff. 8-16-13;
99-143, eff. 7-27-15; 99-870, eff. 8-22-16.)
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other

10100SB1909sam004 - 39 - LRB101 09278 CPF 59162 a
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 women, provided by an individual licensed to practice
dentistry or dental surgery; for purposes of this item (10),
"dental services" means diagnostic, preventive, or corrective
procedures provided by or under the supervision of a dentist in
the practice of his or her profession; (11) physical therapy
and related services; (12) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician
skilled in the diseases of the eye, or by an optometrist,
whichever the person may select; (13) other diagnostic,
screening, preventive, and rehabilitative services, including
to ensure that the individual's need for intervention or
treatment of mental disorders or substance use disorders or
co-occurring mental health and substance use disorders is
determined using a uniform screening, assessment, and
evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a

10100SB1909sam004 - 40 - LRB101 09278 CPF 59162 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; and (17) any other medical
care, and any other type of remedial care recognized under the
laws of this State. The term "any other type of remedial care"
shall include nursing care and nursing home service for persons
who rely on treatment by spiritual means alone through prayer
for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance under

10100SB1909sam004 - 41 - LRB101 09278 CPF 59162 a
this Article.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured under
this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.

10100SB1909sam004 - 42 - LRB101 09278 CPF 59162 a
On and after July 1, 2012, the Department of Healthcare and
Family Services may provide the following services to persons
eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in the
diseases of the eye, or by an optometrist, whichever the
person may select.
On and after July 1, 2018, the Department of Healthcare and
Family Services shall provide dental services to any adult who
is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as set
forth in Exhibit D of the Consent Decree entered by the United
States District Court for the Northern District of Illinois,
Eastern Division, in the matter of Memisovski v. Maram, Case

10100SB1909sam004 - 43 - LRB101 09278 CPF 59162 a
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.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in accordance
with the classes of persons designated in Section 5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)

10100SB1909sam004 - 44 - LRB101 09278 CPF 59162 a
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 women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
(A) A baseline mammogram for women 35 to 39 years of
age.
(B) An annual mammogram for women 40 years of age or
older.
(C) A mammogram at the age and intervals considered
medically necessary by the woman's health care provider for
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.
(D) A comprehensive ultrasound screening and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue, when medically
necessary as determined by a physician licensed to practice
medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
All screenings shall include a physical breast exam,

10100SB1909sam004 - 45 - LRB101 09278 CPF 59162 a
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool. For purposes of this Section, "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. 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 Patient
Protection and Affordable Care Act (Public Law 111-148),
including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
successor provision, to defray the cost of any coverage for
breast tomosynthesis outlined in this paragraph, then the
requirement that an insurer cover breast tomosynthesis is
inoperative other than any such coverage authorized under
Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and

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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.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish

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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
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening mammography.
The Department shall work with experts in breast cancer
outreach and patient navigation to optimize these reminders and
shall establish a methodology for evaluating their
effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot program

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in areas of the State with the highest incidence of mortality
related to breast cancer. At least one pilot program site shall
be in the metropolitan Chicago area and at least one site shall
be outside the metropolitan Chicago area. On or after July 1,
2016, the pilot program shall be expanded to include one site
in western Illinois, one site in southern Illinois, one site in
central Illinois, and 4 sites within metropolitan Chicago. An
evaluation of the pilot program shall be carried out measuring
health outcomes and cost of care for those served by the pilot
program compared to similarly situated patients who are not
served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include access
for patients diagnosed with cancer to at least one academic
commission on cancer-accredited cancer program as an
in-network covered benefit.
On or after July 1, 2019, women who are otherwise eligible
for medical assistance under this Article shall receive
coverage for doula services by a certified doula during their
pregnancy and during the 12-month period beginning on the last
day of their pregnancy. As used in this paragraph, "certified
doula" means an individual who has received a certification to
perform doula services from the International Childbirth

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Education Association, the Doulas of North America, the
Association of Labor Assistants and Childbirth Educators,
BirthWorks, the Childbirth and Postpartum Professional
Association, Childbirth International, the International
Center for Traditional Childbearing, or Commonsense Childbirth
Inc. As used in this paragraph, "doula services" means
continuous personal, non-medical emotional and physical
support throughout labor and birth, and intermittently during
the prenatal and postpartum periods.
On or after July 1, 2019, women 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 woman who is being provided prenatal
services and is suspected of having a substance use disorder as
defined in the Substance Use Disorder Act, referral to a local
substance use disorder treatment program licensed by the
Department of Human Services or to a licensed hospital which
provides substance abuse treatment services. The Department of
Healthcare and Family Services shall assure coverage for the
cost of treatment of the drug abuse or addiction for pregnant
recipients in accordance with the Illinois Medicaid Program in

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conjunction with the Department of Human Services.
All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under any
program providing case management services for addicted women,
including information on appropriate referrals for other
social services that may be needed by addicted women 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 her substance abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for

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medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration projects
in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by rule,
shall develop qualifications for sponsors of Partnerships.
Nothing in this Section shall be construed to require that the
sponsor organization be a medical organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and the
Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by the
Partnership may receive an additional surcharge for such
services.

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(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that provided
services may be accessed from therapeutically certified
optometrists to the full extent of the Illinois Optometric
Practice Act of 1987 without discriminating between service
providers.
The Department shall apply for a waiver from the United

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States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance under
this Article. Such records must be retained for a period of not
less than 6 years from the date of service or as provided by
applicable State law, whichever period is longer, except that
if an audit is initiated within the required retention period
then the records must be retained until the audit is completed
and every exception is resolved. The Illinois Department shall
require health care providers to make available, when
authorized by the patient, in writing, the medical records in a
timely fashion to other health care providers who are treating
or serving persons eligible for Medical Assistance under this
Article. All dispensers of medical services shall be required
to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope,
details and receipt of the health care provided to persons
eligible for medical assistance under this Code, in accordance
with regulations promulgated by the Illinois Department. The
rules and regulations shall require that proof of the receipt
of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of such
medical services. No such claims for reimbursement shall be

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approved for payment by the Illinois Department without such
proof of receipt, unless the Illinois Department shall have put
into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed
adequate by the Illinois Department to assure that such drugs,
dentures, prosthetic devices and eyeglasses for which payment
is being made are actually being received by eligible
recipients. Within 90 days after September 16, 1984 (the
effective date of Public Act 83-1439), the Illinois Department
shall establish a current list of acquisition costs for all
prosthetic devices and any other items recognized as medical
equipment and supplies reimbursable under this Article and
shall update such list on a quarterly basis, except that the
acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section
5-5.12.
Notwithstanding any other law to the contrary, the Illinois
Department shall, within 365 days after July 22, 2013 (the
effective date of Public Act 98-104), establish procedures to
permit skilled care facilities licensed under the Nursing Home
Care Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall, by July 1, 2016, test the viability of the
new system and implement any necessary operational or
structural changes to its information technology platforms in
order to allow for the direct acceptance and payment of nursing

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home claims.
Notwithstanding any other law to the contrary, the Illinois
Department shall, within 365 days after August 15, 2014 (the
effective date of Public Act 98-963), establish procedures to
permit ID/DD facilities licensed under the ID/DD Community Care
Act and MC/DD facilities licensed under the MC/DD Act to submit
monthly billing claims for reimbursement purposes. Following
development of these procedures, the Department shall have an
additional 365 days to test the viability of the new system and
to ensure that any necessary operational or structural changes
to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which

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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 category of risk of
the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.

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The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin

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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 45
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned to
an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has been

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completed, all resubmitted claims following prior rejection
are subject to receipt no later than 180 days after the
admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data necessary
to perform eligibility and payment verifications and other
Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies and departments shall share data necessary for
medical assistance program integrity functions and oversight.

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The Illinois Department shall develop, in cooperation with
other State departments and agencies, and in compliance with
applicable federal laws and regulations, appropriate and
effective methods to share such data. At a minimum, and to the
extent necessary to provide data sharing, the Illinois
Department shall enter into agreements with State agencies and
departments, and is authorized to enter into agreements with
federal agencies and departments, including but not limited to:
the Secretary of State; the Department of Revenue; the
Department of Public Health; the Department of Human Services;
and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- 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,

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procedures, standards and criteria by rule for the acquisition,
repair and replacement of orthotic and prosthetic devices and
durable medical equipment. Such rules shall provide, but not be
limited to, the following services: (1) immediate repair or
replacement of such devices by recipients; and (2) rental,
lease, purchase or lease-purchase of durable medical equipment
in a cost-effective manner, taking into consideration the
recipient's medical prognosis, the extent of the recipient's
needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a
recipient to temporarily acquire and use alternative or
substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized
for such recipient by the Department. Notwithstanding any
provision of Section 5-5f to the contrary, the Department may,
by rule, exempt certain replacement wheelchair parts from prior
approval and, for wheelchairs, wheelchair parts, wheelchair
accessories, and related seating and positioning items,
determine the wholesale price by methods other than actual
acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date of

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the rule adopted pursuant to this paragraph, all providers must
meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant cost
savings, the Department, or a managed care organization under
contract with the Department, may provide recipients or managed
care enrollees who have a prescription or Certificate of
Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs

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of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the State
where they are not currently available or are undeveloped; and
(iii) notwithstanding any other provision of law, subject to
federal approval, on and after July 1, 2012, an increase in the
determination of need (DON) scores from 29 to 37 for applicants
for institutional and home and community-based long term care;
if and only if federal approval is not granted, the Department
may, in conjunction with other affected agencies, implement
utilization controls or changes in benefit packages to
effectuate a similar savings amount for this population; and
(iv) no later than July 1, 2013, minimum level of care
eligibility criteria for institutional and home and
community-based long term care; and (v) no later than October
1, 2013, establish procedures to permit long term care
providers access to eligibility scores for individuals with an

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admission date who are seeking or receiving services from the
long term care provider. In order to select the minimum level
of care eligibility criteria, the Governor shall establish a
workgroup that includes affected agency representatives and
stakeholders representing the institutional and home and
community-based long term care interests. This Section shall
not restrict the Department from implementing lower level of
care eligibility criteria for community-based services in
circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and
programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the

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Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act, and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11 of
this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage

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renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3 of
this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons under
Section 5-2 of this Code. To qualify for coverage of kidney
transplantation, such person must be receiving emergency renal
dialysis services covered by the Department. Providers under
this Section shall be prior approved and certified by the
Department to perform kidney transplantation and the services
under this Section shall be limited to services associated with
kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service 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 related
to the dispensing and administration of the opioid antagonist,

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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.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a dental
hygienist, as defined under the Illinois Dental Practice Act,

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working under the general supervision of a dentist and employed
by a federally qualified health center.
Notwithstanding any other provision of this Code, the
Illinois Department shall authorize licensed dietitian
nutritionists and certified diabetes educators to counsel
senior diabetes patients in the senior diabetes patients' homes
to remove the hurdle of transportation for senior diabetes
patients to receive treatment.
The Department shall seek approval of a State Plan
amendment to expand coverage for family planning services to
women whose income is at or below 200% of the federal poverty
level.
(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
1-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
12-10-18.)
(305 ILCS 5/5-5.24)
Sec. 5-5.24. Prenatal and perinatal care. The Department of
Healthcare and Family Services may provide reimbursement under

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this Article for all prenatal and perinatal health care
services that are provided for the purpose of preventing
low-birthweight infants, reducing the need for neonatal
intensive care hospital services, and promoting perinatal and
maternal health. These services may include comprehensive risk
assessments for pregnant women, women with infants, and
infants, lactation counseling, nutrition counseling,
childbirth support, psychosocial counseling, treatment and
prevention of periodontal disease, language translation, nurse
home visitation, and other support services that have been
proven to improve birth and maternal health outcomes. The
Department shall maximize the use of preventive prenatal and
perinatal health care services consistent with federal
statutes, rules, and regulations. The Department of Public Aid
(now Department of Healthcare and Family Services) shall
develop a plan for prenatal and perinatal preventive health
care and shall present the plan to the General Assembly by
January 1, 2004. On or before January 1, 2006 and every 2 years
thereafter, the Department shall report to the General Assembly
concerning the effectiveness of prenatal and perinatal health
care services reimbursed under this Section in preventing
low-birthweight infants and reducing the need for neonatal
intensive care hospital services. Each such report shall
include an evaluation of how the ratio of expenditures for
treating low-birthweight infants compared with the investment
in promoting healthy births and infants in local community

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areas throughout Illinois relates to healthy infant
development in those areas.
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.
(Source: P.A. 97-689, eff. 6-14-12.)
Section 55. The Developmental Disability Prevention Act is
amended by adding Section 11.2 as follows:
(410 ILCS 250/11.2 new)
Sec. 11.2. Birthing facilities; maternal care
designations.
(a) In this Section, "birthing facility" means: (1) a
hospital, as defined in the Hospital Licensing Act, with more
than one licensed obstetric bed or a neonatal intensive care
unit; (2) a hospital operated by a State university; or (3) a
birth center, as defined in the Alternative Health Care
Delivery Act.
(b) Every birthing facility shall, at a minimum, have an
obstetric hemorrhage protocol and conduct a drill or simulation
of the protocol. Every contracted provider who may encounter a
pregnant woman shall participate in the drill or simulation on
a regular basis. The Department shall adopt rules to implement

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this subsection.
(c) After holding multiple public hearings with
representatives from diverse geographical regions and
professional backgrounds and seeking broad public and
stakeholder input, the Department shall establish criteria for
levels of maternal care designations for birthing facilities.
All hearings shall be open to the public and held at specific
times and places that are convenient and available to the
public. No hearing shall be held on a legal holiday. Public
notice of hearings shall state the dates, times, and places of
the hearings. Notice of hearings shall be posted on the
Department's website and in the Department's main office, and
minutes from the hearings shall be recorded. The levels of
maternal care designations developed under this Section shall
be based upon:
(1) the most current published version of the "Levels
of Maternal Care" developed by the American Congress of
Obstetricians and Gynecologists and the Society for
Maternal-Fetal Medicine; and
(2) necessary variance when considering the geographic
and varied needs of citizens of this State.
(d) Nothing in this Section shall be construed in any way
to modify or expand the licensure of any health care
professional.
(e) Nothing in this Section shall be construed in any way
to require a patient to be transferred to a different facility.

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(f) The Department shall adopt rules to implement the
provisions of this Section no later than June 1, 2021. These
rules shall be limited to those necessary for the establishment
of levels of maternal care designations for birthing facilities
under subsection (c) of this Section.
Section 95. No acceleration or delay. Where this Act makes
changes in a statute that is represented in this Act by text
that is not yet or no longer in effect (for example, a Section
represented by multiple versions), the use of that text does
not accelerate or delay the taking effect of (i) the changes
made by this Act or (ii) provisions derived from any other
Public Act.
Section 99. Effective date. This Act takes effect upon
becoming law.".