Bill Text: IL HB0040 | 2017-2018 | 100th General Assembly | Engrossed

Bill Title: Amends the State Employees Group Insurance Act of 1971. Removes a provision prohibiting the non-contributory portion of a program of health-benefits from including the expenses of obtaining an abortion. Amends the Illinois Public Aid Code. Removes a provision excluding abortions or induced miscarriages or premature births from the list of services provided under the State's medical assistance program. Removes language providing for the adoption of rules to prohibit a physician from providing medical assistance to anyone eligible for medical assistance benefits if the physician has been found guilty of willfully and wantonly performing an abortion procedure upon a woman who was not pregnant at the time of the procedure. Removes other provisions concerning abortion restrictions. Amends the Problem Pregnancy Health Services and Care Act. Removes language prohibiting the Department of Human Services from making grants to nonprofit agencies and organizations that use such grants to refer or counsel for, or perform, abortions. Amends the Illinois Abortion Law of 1975. Provides that it is the intention of the General Assembly to reasonably regulate abortion in conformance with the legal standards set forth in the decisions of the United States Supreme Court of January 22, 1973. Removes language concerning the General Assembly's declaration that the unborn child is a human being from the time of conception and is, therefore, a legal person for purposes of the unborn child's right to life. Makes other changes.

Spectrum: Partisan Bill (Democrat 35-0)

Status: (Engrossed) 2017-04-28 - Added as Alternate Co-Sponsor Sen. David Koehler [HB0040 Detail]

Download: Illinois-2017-HB0040-Engrossed.html

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1 AN ACT concerning abortion.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Sections 6 and 6.1 as follows:
6 (5 ILCS 375/6) (from Ch. 127, par. 526)
7 Sec. 6. Program of health benefits.
8 (a) The program of health benefits shall provide for
9protection against the financial costs of health care expenses
10incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.
17However, nothing in this Act shall be construed to permit, on
18or after July 1, 1980, the non-contributory portion of any such
19program to include the expenses of obtaining an abortion,
20induced miscarriage or induced premature birth unless, in the
21opinion of a physician, such procedures are necessary for the
22preservation of the life of the woman seeking such treatment,
23or except an induced premature birth intended to produce a live

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1viable child and such procedure is necessary for the health of
2the mother or the unborn child. The program may also include
3coverage for those who rely on treatment by prayer or spiritual
4means alone for healing in accordance with the tenets and
5practice of a recognized religious denomination.
6 The program of health benefits shall be designed by the
7Director (1) to provide a reasonable relationship between the
8benefits to be included and the expected distribution of
9expenses of each such type to be incurred by the covered
10members and dependents, (2) to specify, as covered benefits and
11as optional benefits, the medical services of practitioners in
12all categories licensed under the Medical Practice Act of 1987,
13(3) to include reasonable controls, which may include
14deductible and co-insurance provisions, applicable to some or
15all of the benefits, or a coordination of benefits provision,
16to prevent or minimize unnecessary utilization of the various
17hospital, surgical and medical expenses to be provided and to
18provide reasonable assurance of stability of the program, and
19(4) to provide benefits to the extent possible to members
20throughout the State, wherever located, on an equitable basis.
21Notwithstanding any other provision of this Section or Act, for
22all members or dependents who are eligible for benefits under
23Social Security or the Railroad Retirement system or who had
24sufficient Medicare-covered government employment, the
25Department shall reduce benefits which would otherwise be paid
26by Medicare, by the amount of benefits for which the member or

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1dependents are eligible under Medicare, except that such
2reduction in benefits shall apply only to those members or
3dependents who (1) first become eligible for such medicare
4coverage on or after the effective date of this amendatory Act
5of 1992; or (2) are Medicare-eligible members or dependents of
6a local government unit which began participation in the
7program on or after July 1, 1992; or (3) remain eligible for
8but no longer receive Medicare coverage which they had been
9receiving on or after the effective date of this amendatory Act
10of 1992.
11 Notwithstanding any other provisions of this Act, where a
12covered member or dependents are eligible for benefits under
13the federal Medicare health insurance program (Title XVIII of
14the Social Security Act as added by Public Law 89-97, 89th
15Congress), benefits paid under the State of Illinois program or
16plan will be reduced by the amount of benefits paid by
17Medicare. For members or dependents who are eligible for
18benefits under Social Security or the Railroad Retirement
19system or who had sufficient Medicare-covered government
20employment, benefits shall be reduced by the amount for which
21the member or dependent is eligible under Medicare, except that
22such reduction in benefits shall apply only to those members or
23dependents who (1) first become eligible for such Medicare
24coverage on or after the effective date of this amendatory Act
25of 1992; or (2) are Medicare-eligible members or dependents of
26a local government unit which began participation in the

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1program on or after July 1, 1992; or (3) remain eligible for,
2but no longer receive Medicare coverage which they had been
3receiving on or after the effective date of this amendatory Act
4of 1992. Premiums may be adjusted, where applicable, to an
5amount deemed by the Director to be reasonably consistent with
6any reduction of benefits.
7 (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code, shall
11pay the premiums for coverage, not exceeding the amount paid by
12the State for the non-contributory coverage for other members,
13under the group health benefits program under this Act. The
14Director shall determine the premiums to be paid by a member
15under this subsection (b).
16(Source: P.A. 93-47, eff. 7-1-03.)
17 (5 ILCS 375/6.1) (from Ch. 127, par. 526.1)
18 Sec. 6.1. The program of health benefits may offer as an
19alternative, available on an optional basis, coverage through
20health maintenance organizations. That part of the premium for
21such coverage which is in excess of the amount which would
22otherwise be paid by the State for the program of health
23benefits shall be paid by the member who elects such
24alternative coverage and shall be collected as provided for
25premiums for other optional coverages.

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1 However, nothing in this Act shall be construed to permit,
2after the effective date of this amendatory Act of 1983, the
3noncontributory portion of any such program to include the
4expenses of obtaining an abortion, induced miscarriage or
5induced premature birth unless, in the opinion of a physician,
6such procedures are necessary for the preservation of the life
7of the woman seeking such treatment, or except an induced
8premature birth intended to produce a live viable child and
9such procedure is necessary for the health of the mother or her
10unborn child.
11(Source: P.A. 85-848.)
12 Section 10. The Illinois Public Aid Code is amended by
13changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
14 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
15 Sec. 5-5. Medical services. The Illinois Department, by
16rule, shall determine the quantity and quality of and the rate
17of reimbursement for the medical assistance for which payment
18will be authorized, and the medical services to be provided,
19which may include all or part of the following: (1) inpatient
20hospital services; (2) outpatient hospital services; (3) other
21laboratory and X-ray services; (4) skilled nursing home
22services; (5) physicians' services whether furnished in the
23office, the patient's home, a hospital, a skilled nursing home,
24or elsewhere; (6) medical care, or any other type of remedial

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1care furnished by licensed practitioners; (7) home health care
2services; (8) private duty nursing service; (9) clinic
3services; (10) dental services, including prevention and
4treatment of periodontal disease and dental caries disease for
5pregnant women, provided by an individual licensed to practice
6dentistry or dental surgery; for purposes of this item (10),
7"dental services" means diagnostic, preventive, or corrective
8procedures provided by or under the supervision of a dentist in
9the practice of his or her profession; (11) physical therapy
10and related services; (12) prescribed drugs, dentures, and
11prosthetic devices; and eyeglasses prescribed by a physician
12skilled in the diseases of the eye, or by an optometrist,
13whichever the person may select; (13) other diagnostic,
14screening, preventive, and rehabilitative services, including
15to ensure that the individual's need for intervention or
16treatment of mental disorders or substance use disorders or
17co-occurring mental health and substance use disorders is
18determined using a uniform screening, assessment, and
19evaluation process inclusive of criteria, for children and
20adults; for purposes of this item (13), a uniform screening,
21assessment, and evaluation process refers to a process that
22includes an appropriate evaluation and, as warranted, a
23referral; "uniform" does not mean the use of a singular
24instrument, tool, or process that all must utilize; (14)
25transportation and such other expenses as may be necessary;
26(15) medical treatment of sexual assault survivors, as defined

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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the sexual
3assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; and (17) any other medical
7care, and any other type of remedial care recognized under the
8laws of this State, but not including abortions, or induced
9miscarriages or premature births, unless, in the opinion of a
10physician, such procedures are necessary for the preservation
11of the life of the woman seeking such treatment, or except an
12induced premature birth intended to produce a live viable child
13and such procedure is necessary for the health of the mother or
14her unborn child. The Illinois Department, by rule, shall
15prohibit any physician from providing medical assistance to
16anyone eligible therefor under this Code where such physician
17has been found guilty of performing an abortion procedure in a
18wilful and wanton manner upon a woman who was not pregnant at
19the time such abortion procedure was performed. The term "any
20other type of remedial care" shall include nursing care and
21nursing home service for persons who rely on treatment by
22spiritual means alone through prayer for healing.
23 Notwithstanding any other provision of this Section, a
24comprehensive tobacco use cessation program that includes
25purchasing prescription drugs or prescription medical devices
26approved by the Food and Drug Administration shall be covered

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1under the medical assistance program under this Article for
2persons who are otherwise eligible for assistance under this
4 Notwithstanding any other provision of this Code, the
5Illinois Department may not require, as a condition of payment
6for any laboratory test authorized under this Article, that a
7physician's handwritten signature appear on the laboratory
8test order form. The Illinois Department may, however, impose
9other appropriate requirements regarding laboratory test order
11 Upon receipt of federal approval of an amendment to the
12Illinois Title XIX State Plan for this purpose, the Department
13shall authorize the Chicago Public Schools (CPS) to procure a
14vendor or vendors to manufacture eyeglasses for individuals
15enrolled in a school within the CPS system. CPS shall ensure
16that its vendor or vendors are enrolled as providers in the
17medical assistance program and in any capitated Medicaid
18managed care entity (MCE) serving individuals enrolled in a
19school within the CPS system. Under any contract procured under
20this provision, the vendor or vendors must serve only
21individuals enrolled in a school within the CPS system. Claims
22for services provided by CPS's vendor or vendors to recipients
23of benefits in the medical assistance program under this Code,
24the Children's Health Insurance Program, or the Covering ALL
25KIDS Health Insurance Program shall be submitted to the
26Department or the MCE in which the individual is enrolled for

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1payment and shall be reimbursed at the Department's or the
2MCE's established rates or rate methodologies for eyeglasses.
3 On and after July 1, 2012, the Department of Healthcare and
4Family Services may provide the following services to persons
5eligible for assistance under this Article who are
6participating in education, training or employment programs
7operated by the Department of Human Services as successor to
8the Department of Public Aid:
9 (1) dental services provided by or under the
10 supervision of a dentist; and
11 (2) eyeglasses prescribed by a physician skilled in the
12 diseases of the eye, or by an optometrist, whichever the
13 person may select.
14 Notwithstanding any other provision of this Code and
15subject to federal approval, the Department may adopt rules to
16allow a dentist who is volunteering his or her service at no
17cost to render dental services through an enrolled
18not-for-profit health clinic without the dentist personally
19enrolling as a participating provider in the medical assistance
20program. A not-for-profit health clinic shall include a public
21health clinic or Federally Qualified Health Center or other
22enrolled provider, as determined by the Department, through
23which dental services covered under this Section are performed.
24The Department shall establish a process for payment of claims
25for reimbursement for covered dental services rendered under
26this provision.

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1 The Illinois Department, by rule, may distinguish and
2classify the medical services to be provided only in accordance
3with the classes of persons designated in Section 5-2.
4 The Department of Healthcare and Family Services must
5provide coverage and reimbursement for amino acid-based
6elemental formulas, regardless of delivery method, for the
7diagnosis and treatment of (i) eosinophilic disorders and (ii)
8short bowel syndrome when the prescribing physician has issued
9a written order stating that the amino acid-based elemental
10formula is medically necessary.
11 The Illinois Department shall authorize the provision of,
12and shall authorize payment for, screening by low-dose
13mammography for the presence of occult breast cancer for women
1435 years of age or older who are eligible for medical
15assistance under this Article, as follows:
16 (A) A baseline mammogram for women 35 to 39 years of
17 age.
18 (B) An annual mammogram for women 40 years of age or
19 older.
20 (C) A mammogram at the age and intervals considered
21 medically necessary by the woman's health care provider for
22 women under 40 years of age and having a family history of
23 breast cancer, prior personal history of breast cancer,
24 positive genetic testing, or other risk factors.
25 (D) A comprehensive ultrasound screening of an entire
26 breast or breasts if a mammogram demonstrates

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1 heterogeneous or dense breast tissue, when medically
2 necessary as determined by a physician licensed to practice
3 medicine in all of its branches.
4 (E) A screening MRI when medically necessary, as
5 determined by a physician licensed to practice medicine in
6 all of its branches.
7 All screenings shall include a physical breast exam,
8instruction on self-examination and information regarding the
9frequency of self-examination and its value as a preventative
10tool. For purposes of this Section, "low-dose mammography"
11means the x-ray examination of the breast using equipment
12dedicated specifically for mammography, including the x-ray
13tube, filter, compression device, and image receptor, with an
14average radiation exposure delivery of less than one rad per
15breast for 2 views of an average size breast. The term also
16includes digital mammography and includes breast
17tomosynthesis. As used in this Section, the term "breast
18tomosynthesis" means a radiologic procedure that involves the
19acquisition of projection images over the stationary breast to
20produce cross-sectional digital three-dimensional images of
21the breast. If, at any time, the Secretary of the United States
22Department of Health and Human Services, or its successor
23agency, promulgates rules or regulations to be published in the
24Federal Register or publishes a comment in the Federal Register
25or issues an opinion, guidance, or other action that would
26require the State, pursuant to any provision of the Patient

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1Protection and Affordable Care Act (Public Law 111-148),
2including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
3successor provision, to defray the cost of any coverage for
4breast tomosynthesis outlined in this paragraph, then the
5requirement that an insurer cover breast tomosynthesis is
6inoperative other than any such coverage authorized under
7Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
8the State shall not assume any obligation for the cost of
9coverage for breast tomosynthesis set forth in this paragraph.
10 On and after January 1, 2016, the Department shall ensure
11that all networks of care for adult clients of the Department
12include access to at least one breast imaging Center of Imaging
13Excellence as certified by the American College of Radiology.
14 On and after January 1, 2012, providers participating in a
15quality improvement program approved by the Department shall be
16reimbursed for screening and diagnostic mammography at the same
17rate as the Medicare program's rates, including the increased
18reimbursement for digital mammography.
19 The Department shall convene an expert panel including
20representatives of hospitals, free-standing mammography
21facilities, and doctors, including radiologists, to establish
22quality standards for mammography.
23 On and after January 1, 2017, providers participating in a
24breast cancer treatment quality improvement program approved
25by the Department shall be reimbursed for breast cancer
26treatment at a rate that is no lower than 95% of the Medicare

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1program's rates for the data elements included in the breast
2cancer treatment quality program.
3 The Department shall convene an expert panel, including
4representatives of hospitals, free standing breast cancer
5treatment centers, breast cancer quality organizations, and
6doctors, including breast surgeons, reconstructive breast
7surgeons, oncologists, and primary care providers to establish
8quality standards for breast cancer treatment.
9 Subject to federal approval, the Department shall
10establish a rate methodology for mammography at federally
11qualified health centers and other encounter-rate clinics.
12These clinics or centers may also collaborate with other
13hospital-based mammography facilities. By January 1, 2016, the
14Department shall report to the General Assembly on the status
15of the provision set forth in this paragraph.
16 The Department shall establish a methodology to remind
17women who are age-appropriate for screening mammography, but
18who have not received a mammogram within the previous 18
19months, of the importance and benefit of screening mammography.
20The Department shall work with experts in breast cancer
21outreach and patient navigation to optimize these reminders and
22shall establish a methodology for evaluating their
23effectiveness and modifying the methodology based on the
25 The Department shall establish a performance goal for
26primary care providers with respect to their female patients

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1over age 40 receiving an annual mammogram. This performance
2goal shall be used to provide additional reimbursement in the
3form of a quality performance bonus to primary care providers
4who meet that goal.
5 The Department shall devise a means of case-managing or
6patient navigation for beneficiaries diagnosed with breast
7cancer. This program shall initially operate as a pilot program
8in areas of the State with the highest incidence of mortality
9related to breast cancer. At least one pilot program site shall
10be in the metropolitan Chicago area and at least one site shall
11be outside the metropolitan Chicago area. On or after July 1,
122016, the pilot program shall be expanded to include one site
13in western Illinois, one site in southern Illinois, one site in
14central Illinois, and 4 sites within metropolitan Chicago. An
15evaluation of the pilot program shall be carried out measuring
16health outcomes and cost of care for those served by the pilot
17program compared to similarly situated patients who are not
18served by the pilot program.
19 The Department shall require all networks of care to
20develop a means either internally or by contract with experts
21in navigation and community outreach to navigate cancer
22patients to comprehensive care in a timely fashion. The
23Department shall require all networks of care to include access
24for patients diagnosed with cancer to at least one academic
25commission on cancer-accredited cancer program as an
26in-network covered benefit.

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

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1the number of drug-affected infants born to recipients of
2medical assistance.
3 Neither the Department of Healthcare and Family Services
4nor the Department of Human Services shall sanction the
5recipient solely on the basis of her substance abuse.
6 The Illinois Department shall establish such regulations
7governing the dispensing of health services under this Article
8as it shall deem appropriate. The Department should seek the
9advice of formal professional advisory committees appointed by
10the Director of the Illinois Department for the purpose of
11providing regular advice on policy and administrative matters,
12information dissemination and educational activities for
13medical and health care providers, and consistency in
14procedures to the Illinois Department.
15 The Illinois Department may develop and contract with
16Partnerships of medical providers to arrange medical services
17for persons eligible under Section 5-2 of this Code.
18Implementation of this Section may be by demonstration projects
19in certain geographic areas. The Partnership shall be
20represented by a sponsor organization. The Department, by rule,
21shall develop qualifications for sponsors of Partnerships.
22Nothing in this Section shall be construed to require that the
23sponsor organization be a medical organization.
24 The sponsor must negotiate formal written contracts with
25medical providers for physician services, inpatient and
26outpatient hospital care, home health services, treatment for

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

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

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

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1less frequently than every 30 days as required by Section
3 The rules and regulations of the Illinois Department shall
4require that a written statement including the required opinion
5of a physician shall accompany any claim for reimbursement for
6abortions, or induced miscarriages or premature births. This
7statement shall indicate what procedures were used in providing
8such medical services.
9 Notwithstanding any other law to the contrary, the Illinois
10Department shall, within 365 days after July 22, 2013 (the
11effective date of Public Act 98-104), establish procedures to
12permit skilled care facilities licensed under the Nursing Home
13Care Act to submit monthly billing claims for reimbursement
14purposes. Following development of these procedures, the
15Department shall, by July 1, 2016, test the viability of the
16new system and implement any necessary operational or
17structural changes to its information technology platforms in
18order to allow for the direct acceptance and payment of nursing
19home claims.
20 Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after August 15, 2014 (the
22effective date of Public Act 98-963), establish procedures to
23permit ID/DD facilities licensed under the ID/DD Community Care
24Act and MC/DD facilities licensed under the MC/DD Act to submit
25monthly billing claims for reimbursement purposes. Following
26development of these procedures, the Department shall have an

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1additional 365 days to test the viability of the new system and
2to ensure that any necessary operational or structural changes
3to its information technology platforms are implemented.
4 The Illinois Department shall require all dispensers of
5medical services, other than an individual practitioner or
6group of practitioners, desiring to participate in the Medical
7Assistance program established under this Article to disclose
8all financial, beneficial, ownership, equity, surety or other
9interests in any and all firms, corporations, partnerships,
10associations, business enterprises, joint ventures, agencies,
11institutions or other legal entities providing any form of
12health care services in this State under this Article.
13 The Illinois Department may require that all dispensers of
14medical services desiring to participate in the medical
15assistance program established under this Article disclose,
16under such terms and conditions as the Illinois Department may
17by rule establish, all inquiries from clients and attorneys
18regarding medical bills paid by the Illinois Department, which
19inquiries could indicate potential existence of claims or liens
20for the Illinois Department.
21 Enrollment of a vendor shall be subject to a provisional
22period and shall be conditional for one year. During the period
23of conditional enrollment, the Department may terminate the
24vendor's eligibility to participate in, or may disenroll the
25vendor from, the medical assistance program without cause.
26Unless otherwise specified, such termination of eligibility or

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1disenrollment is not subject to the Department's hearing
2process. However, a disenrolled vendor may reapply without
4 The Department has the discretion to limit the conditional
5enrollment period for vendors based upon category of risk of
6the vendor.
7 Prior to enrollment and during the conditional enrollment
8period in the medical assistance program, all vendors shall be
9subject to enhanced oversight, screening, and review based on
10the risk of fraud, waste, and abuse that is posed by the
11category of risk of the vendor. The Illinois Department shall
12establish the procedures for oversight, screening, and review,
13which may include, but need not be limited to: criminal and
14financial background checks; fingerprinting; license,
15certification, and authorization verifications; unscheduled or
16unannounced site visits; database checks; prepayment audit
17reviews; audits; payment caps; payment suspensions; and other
18screening as required by federal or State law.
19 The Department shall define or specify the following: (i)
20by provider notice, the "category of risk of the vendor" for
21each type of vendor, which shall take into account the level of
22screening applicable to a particular category of vendor under
23federal law and regulations; (ii) by rule or provider notice,
24the maximum length of the conditional enrollment period for
25each category of risk of the vendor; and (iii) by rule, the
26hearing rights, if any, afforded to a vendor in each category

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

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

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

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

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

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1eligibility criteria for those persons who are receiving
2non-institutional services; and (ii) the establishment and
3development of non-institutional services in areas of the State
4where they are not currently available or are undeveloped; and
5(iii) notwithstanding any other provision of law, subject to
6federal approval, on and after July 1, 2012, an increase in the
7determination of need (DON) scores from 29 to 37 for applicants
8for institutional and home and community-based long term care;
9if and only if federal approval is not granted, the Department
10may, in conjunction with other affected agencies, implement
11utilization controls or changes in benefit packages to
12effectuate a similar savings amount for this population; and
13(iv) no later than July 1, 2013, minimum level of care
14eligibility criteria for institutional and home and
15community-based long term care; and (v) no later than October
161, 2013, establish procedures to permit long term care
17providers access to eligibility scores for individuals with an
18admission date who are seeking or receiving services from the
19long term care provider. In order to select the minimum level
20of care eligibility criteria, the Governor shall establish a
21workgroup that includes affected agency representatives and
22stakeholders representing the institutional and home and
23community-based long term care interests. This Section shall
24not restrict the Department from implementing lower level of
25care eligibility criteria for community-based services in
26circumstances where federal approval has been granted.

HB0040 Engrossed- 29 -LRB100 04384 KTG 14390 b
1 The Illinois Department shall develop and operate, in
2cooperation with other State Departments and agencies and in
3compliance with applicable federal laws and regulations,
4appropriate and effective systems of health care evaluation and
5programs for monitoring of utilization of health care services
6and facilities, as it affects persons eligible for medical
7assistance under this Code.
8 The Illinois Department shall report annually to the
9General Assembly, no later than the second Friday in April of
101979 and each year thereafter, in regard to:
11 (a) actual statistics and trends in utilization of
12 medical services by public aid recipients;
13 (b) actual statistics and trends in the provision of
14 the various medical services by medical vendors;
15 (c) current rate structures and proposed changes in
16 those rate structures for the various medical vendors; and
17 (d) efforts at utilization review and control by the
18 Illinois Department.
19 The period covered by each report shall be the 3 years
20ending on the June 30 prior to the report. The report shall
21include suggested legislation for consideration by the General
22Assembly. The filing of one copy of the report with the
23Speaker, one copy with the Minority Leader and one copy with
24the Clerk of the House of Representatives, one copy with the
25President, one copy with the Minority Leader and one copy with
26the Secretary of the Senate, one copy with the Legislative

HB0040 Engrossed- 30 -LRB100 04384 KTG 14390 b
1Research Unit, and such additional copies with the State
2Government Report Distribution Center for the General Assembly
3as is required under paragraph (t) of Section 7 of the State
4Library Act shall be deemed sufficient to comply with this
6 Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12 On and after July 1, 2012, the Department shall reduce any
13rate of reimbursement for services or other payments or alter
14any methodologies authorized by this Code to reduce any rate of
15reimbursement for services or other payments in accordance with
16Section 5-5e.
17 Because kidney transplantation can be an appropriate, cost
18effective alternative to renal dialysis when medically
19necessary and notwithstanding the provisions of Section 1-11 of
20this Code, beginning October 1, 2014, the Department shall
21cover kidney transplantation for noncitizens with end-stage
22renal disease who are not eligible for comprehensive medical
23benefits, who meet the residency requirements of Section 5-3 of
24this Code, and who would otherwise meet the financial
25requirements of the appropriate class of eligible persons under
26Section 5-2 of this Code. To qualify for coverage of kidney

HB0040 Engrossed- 31 -LRB100 04384 KTG 14390 b
1transplantation, such person must be receiving emergency renal
2dialysis services covered by the Department. Providers under
3this Section shall be prior approved and certified by the
4Department to perform kidney transplantation and the services
5under this Section shall be limited to services associated with
6kidney transplantation.
7 Notwithstanding any other provision of this Code to the
8contrary, on or after July 1, 2015, all FDA approved forms of
9medication assisted treatment prescribed for the treatment of
10alcohol dependence or treatment of opioid dependence shall be
11covered under both fee for service and managed care medical
12assistance programs for persons who are otherwise eligible for
13medical assistance under this Article and shall not be subject
14to any (1) utilization control, other than those established
15under the American Society of Addiction Medicine patient
16placement criteria, (2) prior authorization mandate, or (3)
17lifetime restriction limit mandate.
18 On or after July 1, 2015, opioid antagonists prescribed for
19the treatment of an opioid overdose, including the medication
20product, administration devices, and any pharmacy fees related
21to the dispensing and administration of the opioid antagonist,
22shall be covered under the medical assistance program for
23persons who are otherwise eligible for medical assistance under
24this Article. As used in this Section, "opioid antagonist"
25means a drug that binds to opioid receptors and blocks or
26inhibits the effect of opioids acting on those receptors,

HB0040 Engrossed- 32 -LRB100 04384 KTG 14390 b
1including, but not limited to, naloxone hydrochloride or any
2other similarly acting drug approved by the U.S. Food and Drug
4 Upon federal approval, the Department shall provide
5coverage and reimbursement for all drugs that are approved for
6marketing by the federal Food and Drug Administration and that
7are recommended by the federal Public Health Service or the
8United States Centers for Disease Control and Prevention for
9pre-exposure prophylaxis and related pre-exposure prophylaxis
10services, including, but not limited to, HIV and sexually
11transmitted infection screening, treatment for sexually
12transmitted infections, medical monitoring, assorted labs, and
13counseling to reduce the likelihood of HIV infection among
14individuals who are not infected with HIV but who are at high
15risk of HIV infection.
16(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1798-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
188-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
19eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2099-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2120 of P.A. 99-588 for the effective date of P.A. 99-407);
2299-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
237-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
24eff. 1-1-17; revised 9-20-16.)
25 (305 ILCS 5/5-8) (from Ch. 23, par. 5-8)

HB0040 Engrossed- 33 -LRB100 04384 KTG 14390 b
1 Sec. 5-8. Practitioners. In supplying medical assistance,
2the Illinois Department may provide for the legally authorized
3services of (i) persons licensed under the Medical Practice Act
4of 1987, as amended, except as hereafter in this Section
5stated, whether under a general or limited license, (ii)
6persons licensed under the Nurse Practice Act as advanced
7practice nurses, regardless of whether or not the persons have
8written collaborative agreements, (iii) persons licensed or
9registered under other laws of this State to provide dental,
10medical, pharmaceutical, optometric, podiatric, or nursing
11services, or other remedial care recognized under State law,
12and (iv) persons licensed under other laws of this State as a
13clinical social worker. The Department shall adopt rules, no
14later than 90 days after the effective date of this amendatory
15Act of the 99th General Assembly, for the legally authorized
16services of persons licensed under other laws of this State as
17a clinical social worker. The Department may not provide for
18legally authorized services of any physician who has been
19convicted of having performed an abortion procedure in a wilful
20and wanton manner on a woman who was not pregnant at the time
21such abortion procedure was performed. The utilization of the
22services of persons engaged in the treatment or care of the
23sick, which persons are not required to be licensed or
24registered under the laws of this State, is not prohibited by
25this Section.
26(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17.)

HB0040 Engrossed- 34 -LRB100 04384 KTG 14390 b
1 (305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
2 Sec. 5-9. Choice of Medical Dispensers. Applicants and
3recipients shall be entitled to free choice of those qualified
4practitioners, hospitals, nursing homes, and other dispensers
5of medical services meeting the requirements and complying with
6the rules and regulations of the Illinois Department. However,
7the Director of Healthcare and Family Services may, after
8providing reasonable notice and opportunity for hearing, deny,
9suspend or terminate any otherwise qualified person, firm,
10corporation, association, agency, institution, or other legal
11entity, from participation as a vendor of goods or services
12under the medical assistance program authorized by this Article
13if the Director finds such vendor of medical services in
14violation of this Act or the policy or rules and regulations
15issued pursuant to this Act. Any physician who has been
16convicted of performing an abortion procedure in a wilful and
17wanton manner upon a woman who was not pregnant at the time
18such abortion procedure was performed shall be automatically
19removed from the list of physicians qualified to participate as
20a vendor of medical services under the medical assistance
21program authorized by this Article.
22(Source: P.A. 95-331, eff. 8-21-07.)
23 (305 ILCS 5/6-1) (from Ch. 23, par. 6-1)
24 Sec. 6-1. Eligibility requirements. Financial aid in

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1meeting basic maintenance requirements shall be given under
2this Article to or in behalf of persons who meet the
3eligibility conditions of Sections 6-1.1 through 6-1.10. In
4addition, each unit of local government subject to this Article
5shall provide persons receiving financial aid in meeting basic
6maintenance requirements with financial aid for either (a)
7necessary treatment, care, and supplies required because of
8illness or disability, or (b) acute medical treatment, care,
9and supplies only. If a local governmental unit elects to
10provide financial aid for acute medical treatment, care, and
11supplies only, the general types of acute medical treatment,
12care, and supplies for which financial aid is provided shall be
13specified in the general assistance rules of the local
14governmental unit, which rules shall provide that financial aid
15is provided, at a minimum, for acute medical treatment, care,
16or supplies necessitated by a medical condition for which prior
17approval or authorization of medical treatment, care, or
18supplies is not required by the general assistance rules of the
19Illinois Department. Nothing in this Article shall be construed
20to permit the granting of financial aid where the purpose of
21such aid is to obtain an abortion, induced miscarriage or
22induced premature birth unless, in the opinion of a physician,
23such procedures are necessary for the preservation of the life
24of the woman seeking such treatment, or except an induced
25premature birth intended to produce a live viable child and
26such procedure is necessary for the health of the mother or her

HB0040 Engrossed- 36 -LRB100 04384 KTG 14390 b
1unborn child.
2(Source: P.A. 92-111, eff. 1-1-02.)
3 Section 15. The Problem Pregnancy Health Services and Care
4Act is amended by changing Section 4-100 as follows:
5 (410 ILCS 230/4-100) (from Ch. 111 1/2, par. 4604-100)
6 Sec. 4-100. The Department may make grants to nonprofit
7agencies and organizations which do not use such grants to
8refer or counsel for, or perform, abortions and which
9coordinate and establish linkages among services that will
10further the purposes of this Act and, where appropriate, will
11provide, supplement, or improve the quality of such services.
12(Source: P.A. 83-51.)
13 Section 20. The Illinois Abortion Law of 1975 is amended by
14changing Section 1 as follows:
15 (720 ILCS 510/1) (from Ch. 38, par. 81-21)
16 Sec. 1. It is the intention of the General Assembly of the
17State of Illinois to reasonably regulate abortion in
18conformance with the legal standards set forth in the decisions
19of the United States Supreme Court of January 22, 1973. Without
20in any way restricting the right of privacy of a woman or the
21right of a woman to an abortion under those decisions, the
22General Assembly of the State of Illinois do solemnly declare

HB0040 Engrossed- 37 -LRB100 04384 KTG 14390 b
1and find in reaffirmation of the longstanding policy of this
2State, that the unborn child is a human being from the time of
3conception and is, therefore, a legal person for purposes of
4the unborn child's right to life and is entitled to the right
5to life from conception under the laws and Constitution of this
6State. Further, the General Assembly finds and declares that
7longstanding policy of this State to protect the right to life
8of the unborn child from conception by prohibiting abortion
9unless necessary to preserve the life of the mother is
10impermissible only because of the decisions of the United
11States Supreme Court and that, therefore, if those decisions of
12the United States Supreme Court are ever reversed or modified
13or the United States Constitution is amended to allow
14protection of the unborn then the former policy of this State
15to prohibit abortions unless necessary for the preservation of
16the mother's life shall be reinstated.
17 It is the further intention of the General Assembly to
18assure and protect the woman's health and the integrity of the
19woman's decision whether or not to continue to bear a child, to
20protect the valid and compelling state interest in the infant
21and unborn child, to assure the integrity of marital and
22familial relations and the rights and interests of persons who
23participate in such relations, and to gather data for
24establishing criteria for medical decisions. The General
25Assembly finds as fact, upon hearings and public disclosures,
26that these rights and interests are not secure in the economic

HB0040 Engrossed- 38 -LRB100 04384 KTG 14390 b
1and social context in which abortion is presently performed.
2(Source: P.A. 81-1078.)

HB0040 Engrossed- 39 -LRB100 04384 KTG 14390 b
2 Statutes amended in order of appearance