Bill Text: IL SB0162 | 2019-2020 | 101st General Assembly | Engrossed


Bill Title: Amends the Counties Code, the Illinois Municipal Code, Illinois Insurance Code, the Health Maintenance Organization Act, and the Illinois Public Aid Code. In provisions concerning coverage for mammograms, provides that coverage shall also include a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant. Makes changes to coverage for a comprehensive ultrasound screening and MRI. Effective immediately.

Spectrum: Moderate Partisan Bill (Democrat 52-8)

Status: (Engrossed) 2019-05-24 - Alternate Co-Sponsor Removed Rep. Mark Batinick [SB0162 Detail]

Download: Illinois-2019-SB0162-Engrossed.html



SB0162 EngrossedLRB101 07839 SMS 52893 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Counties Code is amended by changing Section
55-1069 as follows:
6 (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
7 Sec. 5-1069. Group life, health, accident, hospital, and
8medical insurance.
9 (a) The county board of any county may arrange to provide,
10for the benefit of employees of the county, group life, health,
11accident, hospital, and medical insurance, or any one or any
12combination of those types of insurance, or the county board
13may self-insure, for the benefit of its employees, all or a
14portion of the employees' group life, health, accident,
15hospital, and medical insurance, or any one or any combination
16of those types of insurance, including a combination of
17self-insurance and other types of insurance authorized by this
18Section, provided that the county board complies with all other
19requirements of this Section. The insurance may include
20provision for employees who rely on treatment by prayer or
21spiritual means alone for healing in accordance with the tenets
22and practice of a well recognized religious denomination. The
23county board may provide for payment by the county of a portion

SB0162 Engrossed- 2 -LRB101 07839 SMS 52893 b
1or all of the premium or charge for the insurance with the
2employee paying the balance of the premium or charge, if any.
3If the county board undertakes a plan under which the county
4pays only a portion of the premium or charge, the county board
5shall provide for withholding and deducting from the
6compensation of those employees who consent to join the plan
7the balance of the premium or charge for the insurance.
8 (b) If the county board does not provide for self-insurance
9or for a plan under which the county pays a portion or all of
10the premium or charge for a group insurance plan, the county
11board may provide for withholding and deducting from the
12compensation of those employees who consent thereto the total
13premium or charge for any group life, health, accident,
14hospital, and medical insurance.
15 (c) The county board may exercise the powers granted in
16this Section only if it provides for self-insurance or, where
17it makes arrangements to provide group insurance through an
18insurance carrier, if the kinds of group insurance are obtained
19from an insurance company authorized to do business in the
20State of Illinois. The county board may enact an ordinance
21prescribing the method of operation of the insurance program.
22 (d) If a county, including a home rule county, is a
23self-insurer for purposes of providing health insurance
24coverage for its employees, the insurance coverage shall
25include screening by low-dose mammography for all women 35
26years of age or older for the presence of occult breast cancer

SB0162 Engrossed- 3 -LRB101 07839 SMS 52893 b
1unless the county elects to provide mammograms itself under
2Section 5-1069.1. The coverage shall be as follows:
3 (1) A baseline mammogram for women 35 to 39 years of
4 age.
5 (2) An annual mammogram for women 40 years of age or
6 older.
7 (3) A mammogram at the age and intervals considered
8 medically necessary by the woman's health care provider for
9 women under 40 years of age and having a family history of
10 breast cancer, prior personal history of breast cancer,
11 positive genetic testing, or other risk factors.
12 (4) For a group policy of accident and health insurance
13 that is amended, delivered, issued, or renewed on or after
14 the effective date of this amendatory Act of the 101st
15 General Assembly, a A comprehensive ultrasound screening
16 of an entire breast or breasts if a mammogram demonstrates
17 heterogeneous or dense breast tissue or , when medically
18 necessary as determined by a physician licensed to practice
19 medicine in all of its branches, advanced practice
20 registered nurse, or physician assistant.
21 (5) For a group policy of accident and health insurance
22 that is amended, delivered, issued, or renewed on or after
23 the effective date of this amendatory Act of the 101st
24 General Assembly, a diagnostic mammogram when medically
25 necessary, as determined by a physician licensed to
26 practice medicine in all its branches, advanced practice

SB0162 Engrossed- 4 -LRB101 07839 SMS 52893 b
1 registered nurse, or physician assistant.
2 A policy subject to this subsection shall not impose a
3deductible, coinsurance, copayment, or any other cost-sharing
4requirement on the coverage provided; except that this sentence
5does not apply to coverage of diagnostic mammograms to the
6extent such coverage would disqualify a high-deductible health
7plan from eligibility for a health savings account pursuant to
8Section 223 of the Internal Revenue Code (26 U.S.C. 223).
9 For purposes of this subsection: ,
10 "Diagnostic mammogram" means a mammogram obtained using
11diagnostic mammography.
12 "Diagnostic mammography" means a method of screening that
13is designed to evaluate an abnormality in a breast, including
14an abnormality seen or suspected on a screening mammogram or a
15subjective or objective abnormality otherwise detected in the
16breast.
17 "Low-dose low-dose mammography" means the x-ray
18examination of the breast using equipment dedicated
19specifically for mammography, including the x-ray tube,
20filter, compression device, and image receptor, with an average
21radiation exposure delivery of less than one rad per breast for
222 views of an average size breast. The term also includes
23digital mammography.
24 (d-5) Coverage as described by subsection (d) shall be
25provided at no cost to the insured and shall not be applied to
26an annual or lifetime maximum benefit.

SB0162 Engrossed- 5 -LRB101 07839 SMS 52893 b
1 (d-10) When health care services are available through
2contracted providers and a person does not comply with plan
3provisions specific to the use of contracted providers, the
4requirements of subsection (d-5) are not applicable. When a
5person does not comply with plan provisions specific to the use
6of contracted providers, plan provisions specific to the use of
7non-contracted providers must be applied without distinction
8for coverage required by this Section and shall be at least as
9favorable as for other radiological examinations covered by the
10policy or contract.
11 (d-15) If a county, including a home rule county, is a
12self-insurer for purposes of providing health insurance
13coverage for its employees, the insurance coverage shall
14include mastectomy coverage, which includes coverage for
15prosthetic devices or reconstructive surgery incident to the
16mastectomy. Coverage for breast reconstruction in connection
17with a mastectomy shall include:
18 (1) reconstruction of the breast upon which the
19 mastectomy has been performed;
20 (2) surgery and reconstruction of the other breast to
21 produce a symmetrical appearance; and
22 (3) prostheses and treatment for physical
23 complications at all stages of mastectomy, including
24 lymphedemas.
25Care shall be determined in consultation with the attending
26physician and the patient. The offered coverage for prosthetic

SB0162 Engrossed- 6 -LRB101 07839 SMS 52893 b
1devices and reconstructive surgery shall be subject to the
2deductible and coinsurance conditions applied to the
3mastectomy, and all other terms and conditions applicable to
4other benefits. When a mastectomy is performed and there is no
5evidence of malignancy then the offered coverage may be limited
6to the provision of prosthetic devices and reconstructive
7surgery to within 2 years after the date of the mastectomy. As
8used in this Section, "mastectomy" means the removal of all or
9part of the breast for medically necessary reasons, as
10determined by a licensed physician.
11 A county, including a home rule county, that is a
12self-insurer for purposes of providing health insurance
13coverage for its employees, may not penalize or reduce or limit
14the reimbursement of an attending provider or provide
15incentives (monetary or otherwise) to an attending provider to
16induce the provider to provide care to an insured in a manner
17inconsistent with this Section.
18 (d-20) The requirement that mammograms be included in
19health insurance coverage as provided in subsections (d)
20through (d-15) is an exclusive power and function of the State
21and is a denial and limitation under Article VII, Section 6,
22subsection (h) of the Illinois Constitution of home rule county
23powers. A home rule county to which subsections (d) through
24(d-15) apply must comply with every provision of those
25subsections.
26 (e) The term "employees" as used in this Section includes

SB0162 Engrossed- 7 -LRB101 07839 SMS 52893 b
1elected or appointed officials but does not include temporary
2employees.
3 (f) The county board may, by ordinance, arrange to provide
4group life, health, accident, hospital, and medical insurance,
5or any one or a combination of those types of insurance, under
6this Section to retired former employees and retired former
7elected or appointed officials of the county.
8 (g) Rulemaking authority to implement this amendatory Act
9of the 95th General Assembly, if any, is conditioned on the
10rules being adopted in accordance with all provisions of the
11Illinois Administrative Procedure Act and all rules and
12procedures of the Joint Committee on Administrative Rules; any
13purported rule not so adopted, for whatever reason, is
14unauthorized.
15(Source: P.A. 99-581, eff. 1-1-17; 100-513, eff. 1-1-18.)
16 Section 10. The Illinois Municipal Code is amended by
17changing Section 10-4-2 as follows:
18 (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
19 Sec. 10-4-2. Group insurance.
20 (a) The corporate authorities of any municipality may
21arrange to provide, for the benefit of employees of the
22municipality, group life, health, accident, hospital, and
23medical insurance, or any one or any combination of those types
24of insurance, and may arrange to provide that insurance for the

SB0162 Engrossed- 8 -LRB101 07839 SMS 52893 b
1benefit of the spouses or dependents of those employees. The
2insurance may include provision for employees or other insured
3persons who rely on treatment by prayer or spiritual means
4alone for healing in accordance with the tenets and practice of
5a well recognized religious denomination. The corporate
6authorities may provide for payment by the municipality of a
7portion of the premium or charge for the insurance with the
8employee paying the balance of the premium or charge. If the
9corporate authorities undertake a plan under which the
10municipality pays a portion of the premium or charge, the
11corporate authorities shall provide for withholding and
12deducting from the compensation of those municipal employees
13who consent to join the plan the balance of the premium or
14charge for the insurance.
15 (b) If the corporate authorities do not provide for a plan
16under which the municipality pays a portion of the premium or
17charge for a group insurance plan, the corporate authorities
18may provide for withholding and deducting from the compensation
19of those employees who consent thereto the premium or charge
20for any group life, health, accident, hospital, and medical
21insurance.
22 (c) The corporate authorities may exercise the powers
23granted in this Section only if the kinds of group insurance
24are obtained from an insurance company authorized to do
25business in the State of Illinois, or are obtained through an
26intergovernmental joint self-insurance pool as authorized

SB0162 Engrossed- 9 -LRB101 07839 SMS 52893 b
1under the Intergovernmental Cooperation Act. The corporate
2authorities may enact an ordinance prescribing the method of
3operation of the insurance program.
4 (d) If a municipality, including a home rule municipality,
5is a self-insurer for purposes of providing health insurance
6coverage for its employees, the insurance coverage shall
7include screening by low-dose mammography for all women 35
8years of age or older for the presence of occult breast cancer
9unless the municipality elects to provide mammograms itself
10under Section 10-4-2.1. The coverage shall be as follows:
11 (1) A baseline mammogram for women 35 to 39 years of
12 age.
13 (2) An annual mammogram for women 40 years of age or
14 older.
15 (3) A mammogram at the age and intervals considered
16 medically necessary by the woman's health care provider for
17 women under 40 years of age and having a family history of
18 breast cancer, prior personal history of breast cancer,
19 positive genetic testing, or other risk factors.
20 (4) For a group policy of accident and health insurance
21 that is amended, delivered, issued, or renewed on or after
22 the effective date of this amendatory Act of the 101st
23 General Assembly, a A comprehensive ultrasound screening
24 of an entire breast or breasts if a mammogram demonstrates
25 heterogeneous or dense breast tissue or , when medically
26 necessary as determined by a physician licensed to practice

SB0162 Engrossed- 10 -LRB101 07839 SMS 52893 b
1 medicine in all of its branches.
2 (5) For a group policy of accident and health insurance
3 that is amended, delivered, issued, or renewed on or after
4 the effective date of this amendatory Act of the 101st
5 General Assembly, a diagnostic mammogram when medically
6 necessary, as determined by a physician licensed to
7 practice medicine in all its branches, advanced practice
8 registered nurse, or physician assistant.
9 A policy subject to this subsection shall not impose a
10deductible, coinsurance, copayment, or any other cost-sharing
11requirement on the coverage provided; except that this sentence
12does not apply to coverage of diagnostic mammograms to the
13extent such coverage would disqualify a high-deductible health
14plan from eligibility for a health savings account pursuant to
15Section 223 of the Internal Revenue Code (26 U.S.C. 223).
16 For purposes of this subsection: ,
17 "Diagnostic mammogram" means a mammogram obtained using
18diagnostic mammography.
19 "Diagnostic mammography" means a method of screening that
20is designed to evaluate an abnormality in a breast, including
21an abnormality seen or suspected on a screening mammogram or a
22subjective or objective abnormality otherwise detected in the
23breast.
24 "Low-dose low-dose mammography" means the x-ray
25examination of the breast using equipment dedicated
26specifically for mammography, including the x-ray tube,

SB0162 Engrossed- 11 -LRB101 07839 SMS 52893 b
1filter, compression device, and image receptor, with an average
2radiation exposure delivery of less than one rad per breast for
32 views of an average size breast. The term also includes
4digital mammography.
5 (d-5) Coverage as described by subsection (d) shall be
6provided at no cost to the insured and shall not be applied to
7an annual or lifetime maximum benefit.
8 (d-10) When health care services are available through
9contracted providers and a person does not comply with plan
10provisions specific to the use of contracted providers, the
11requirements of subsection (d-5) are not applicable. When a
12person does not comply with plan provisions specific to the use
13of contracted providers, plan provisions specific to the use of
14non-contracted providers must be applied without distinction
15for coverage required by this Section and shall be at least as
16favorable as for other radiological examinations covered by the
17policy or contract.
18 (d-15) If a municipality, including a home rule
19municipality, is a self-insurer for purposes of providing
20health insurance coverage for its employees, the insurance
21coverage shall include mastectomy coverage, which includes
22coverage for prosthetic devices or reconstructive surgery
23incident to the mastectomy. Coverage for breast reconstruction
24in connection with a mastectomy shall include:
25 (1) reconstruction of the breast upon which the
26 mastectomy has been performed;

SB0162 Engrossed- 12 -LRB101 07839 SMS 52893 b
1 (2) surgery and reconstruction of the other breast to
2 produce a symmetrical appearance; and
3 (3) prostheses and treatment for physical
4 complications at all stages of mastectomy, including
5 lymphedemas.
6Care shall be determined in consultation with the attending
7physician and the patient. The offered coverage for prosthetic
8devices and reconstructive surgery shall be subject to the
9deductible and coinsurance conditions applied to the
10mastectomy, and all other terms and conditions applicable to
11other benefits. When a mastectomy is performed and there is no
12evidence of malignancy then the offered coverage may be limited
13to the provision of prosthetic devices and reconstructive
14surgery to within 2 years after the date of the mastectomy. As
15used in this Section, "mastectomy" means the removal of all or
16part of the breast for medically necessary reasons, as
17determined by a licensed physician.
18 A municipality, including a home rule municipality, that is
19a self-insurer for purposes of providing health insurance
20coverage for its employees, may not penalize or reduce or limit
21the reimbursement of an attending provider or provide
22incentives (monetary or otherwise) to an attending provider to
23induce the provider to provide care to an insured in a manner
24inconsistent with this Section.
25 (d-20) The requirement that mammograms be included in
26health insurance coverage as provided in subsections (d)

SB0162 Engrossed- 13 -LRB101 07839 SMS 52893 b
1through (d-15) is an exclusive power and function of the State
2and is a denial and limitation under Article VII, Section 6,
3subsection (h) of the Illinois Constitution of home rule
4municipality powers. A home rule municipality to which
5subsections (d) through (d-15) apply must comply with every
6provision of those subsections.
7 (e) Rulemaking authority to implement Public Act 95-1045,
8if any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 100-863, eff. 8-14-18.)
14 Section 15. The Illinois Insurance Code is amended by
15changing Section 356g as follows:
16 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
17 Sec. 356g. Mammograms; mastectomies.
18 (a) Every insurer shall provide in each group or individual
19policy, contract, or certificate of insurance issued or renewed
20for persons who are residents of this State, coverage for
21screening by low-dose mammography for all women 35 years of age
22or older for the presence of occult breast cancer within the
23provisions of the policy, contract, or certificate. The
24coverage shall be as follows:

SB0162 Engrossed- 14 -LRB101 07839 SMS 52893 b
1 (1) A baseline mammogram for women 35 to 39 years of
2 age.
3 (2) An annual mammogram for women 40 years of age or
4 older.
5 (3) A mammogram at the age and intervals considered
6 medically necessary by the woman's health care provider for
7 women under 40 years of age and having a family history of
8 breast cancer, prior personal history of breast cancer,
9 positive genetic testing, or other risk factors.
10 (4) For an individual or group policy of accident and
11 health insurance or a managed care plan that is amended,
12 delivered, issued, or renewed on or after the effective
13 date of this amendatory Act of the 101st General Assembly,
14 a A comprehensive ultrasound screening and MRI of an entire
15 breast or breasts if a mammogram demonstrates
16 heterogeneous or dense breast tissue or , when medically
17 necessary as determined by a physician licensed to practice
18 medicine in all of its branches.
19 (5) A screening MRI when medically necessary, as
20 determined by a physician licensed to practice medicine in
21 all of its branches.
22 (6) For an individual or group policy of accident and
23 health insurance or a managed care plan that is amended,
24 delivered, issued, or renewed on or after the effective
25 date of this amendatory Act of the 101st General Assembly,
26 a diagnostic mammogram when medically necessary, as

SB0162 Engrossed- 15 -LRB101 07839 SMS 52893 b
1 determined by a physician licensed to practice medicine in
2 all its branches, advanced practice registered nurse, or
3 physician assistant.
4 A policy subject to this subsection shall not impose a
5deductible, coinsurance, copayment, or any other cost-sharing
6requirement on the coverage provided; except that this sentence
7does not apply to coverage of diagnostic mammograms to the
8extent such coverage would disqualify a high-deductible health
9plan from eligibility for a health savings account pursuant to
10Section 223 of the Internal Revenue Code (26 U.S.C. 223).
11 For purposes of this Section: ,
12 "Diagnostic mammogram" means a mammogram obtained using
13diagnostic mammography.
14 "Diagnostic mammography" means a method of screening that
15is designed to evaluate an abnormality in a breast, including
16an abnormality seen or suspected on a screening mammogram or a
17subjective or objective abnormality otherwise detected in the
18breast.
19 "Low-dose low-dose mammography" means the x-ray
20examination of the breast using equipment dedicated
21specifically for mammography, including the x-ray tube,
22filter, compression device, and image receptor, with radiation
23exposure delivery of less than 1 rad per breast for 2 views of
24an average size breast. The term also includes digital
25mammography and includes breast tomosynthesis. As used in this
26Section, the term "breast tomosynthesis" means a radiologic

SB0162 Engrossed- 16 -LRB101 07839 SMS 52893 b
1procedure that involves the acquisition of projection images
2over the stationary breast to produce cross-sectional digital
3three-dimensional images of the breast.
4 If, at any time, the Secretary of the United States
5Department of Health and Human Services, or its successor
6agency, promulgates rules or regulations to be published in the
7Federal Register or publishes a comment in the Federal Register
8or issues an opinion, guidance, or other action that would
9require the State, pursuant to any provision of the Patient
10Protection and Affordable Care Act (Public Law 111-148),
11including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
12successor provision, to defray the cost of any coverage for
13breast tomosynthesis outlined in this subsection, then the
14requirement that an insurer cover breast tomosynthesis is
15inoperative other than any such coverage authorized under
16Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
17the State shall not assume any obligation for the cost of
18coverage for breast tomosynthesis set forth in this subsection.
19 (a-5) Coverage as described by subsection (a) shall be
20provided at no cost to the insured and shall not be applied to
21an annual or lifetime maximum benefit.
22 (a-10) When health care services are available through
23contracted providers and a person does not comply with plan
24provisions specific to the use of contracted providers, the
25requirements of subsection (a-5) are not applicable. When a
26person does not comply with plan provisions specific to the use

SB0162 Engrossed- 17 -LRB101 07839 SMS 52893 b
1of contracted providers, plan provisions specific to the use of
2non-contracted providers must be applied without distinction
3for coverage required by this Section and shall be at least as
4favorable as for other radiological examinations covered by the
5policy or contract.
6 (b) No policy of accident or health insurance that provides
7for the surgical procedure known as a mastectomy shall be
8issued, amended, delivered, or renewed in this State unless
9that coverage also provides for prosthetic devices or
10reconstructive surgery incident to the mastectomy. Coverage
11for breast reconstruction in connection with a mastectomy shall
12include:
13 (1) reconstruction of the breast upon which the
14 mastectomy has been performed;
15 (2) surgery and reconstruction of the other breast to
16 produce a symmetrical appearance; and
17 (3) prostheses and treatment for physical
18 complications at all stages of mastectomy, including
19 lymphedemas.
20Care shall be determined in consultation with the attending
21physician and the patient. The offered coverage for prosthetic
22devices and reconstructive surgery shall be subject to the
23deductible and coinsurance conditions applied to the
24mastectomy, and all other terms and conditions applicable to
25other benefits. When a mastectomy is performed and there is no
26evidence of malignancy then the offered coverage may be limited

SB0162 Engrossed- 18 -LRB101 07839 SMS 52893 b
1to the provision of prosthetic devices and reconstructive
2surgery to within 2 years after the date of the mastectomy. As
3used in this Section, "mastectomy" means the removal of all or
4part of the breast for medically necessary reasons, as
5determined by a licensed physician.
6 Written notice of the availability of coverage under this
7Section shall be delivered to the insured upon enrollment and
8annually thereafter. An insurer may not deny to an insured
9eligibility, or continued eligibility, to enroll or to renew
10coverage under the terms of the plan solely for the purpose of
11avoiding the requirements of this Section. An insurer may not
12penalize or reduce or limit the reimbursement of an attending
13provider or provide incentives (monetary or otherwise) to an
14attending provider to induce the provider to provide care to an
15insured in a manner inconsistent with this Section.
16 (c) Rulemaking authority to implement Public Act 95-1045,
17if any, is conditioned on the rules being adopted in accordance
18with all provisions of the Illinois Administrative Procedure
19Act and all rules and procedures of the Joint Committee on
20Administrative Rules; any purported rule not so adopted, for
21whatever reason, is unauthorized.
22(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
23effective date of P.A. 99-407); 99-433, eff. 8-21-15; 99-588,
24eff. 7-20-16; 99-642, eff. 7-28-16; 100-395, eff. 1-1-18.)
25 Section 20. The Health Maintenance Organization Act is

SB0162 Engrossed- 19 -LRB101 07839 SMS 52893 b
1amended by changing Section 4-6.1 as follows:
2 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
3 Sec. 4-6.1. Mammograms; mastectomies.
4 (a) Every contract or evidence of coverage issued by a
5Health Maintenance Organization for persons who are residents
6of this State shall contain coverage for screening by low-dose
7mammography for all women 35 years of age or older for the
8presence of occult breast cancer. The coverage shall be as
9follows:
10 (1) A baseline mammogram for women 35 to 39 years of
11 age.
12 (2) An annual mammogram for women 40 years of age or
13 older.
14 (3) A mammogram at the age and intervals considered
15 medically necessary by the woman's health care provider for
16 women under 40 years of age and having a family history of
17 breast cancer, prior personal history of breast cancer,
18 positive genetic testing, or other risk factors.
19 (4) For an individual or group policy of accident and
20 health insurance or a managed care plan that is amended,
21 delivered, issued, or renewed on or after the effective
22 date of this amendatory Act of the 101st General Assembly,
23 a A comprehensive ultrasound screening and MRI of an entire
24 breast or breasts if a mammogram demonstrates
25 heterogeneous or dense breast tissue or , when medically

SB0162 Engrossed- 20 -LRB101 07839 SMS 52893 b
1 necessary as determined by a physician licensed to practice
2 medicine in all of its branches.
3 (5) For an individual or group policy of accident and
4 health insurance or a managed care plan that is amended,
5 delivered, issued, or renewed on or after the effective
6 date of this amendatory Act of the 101st General Assembly,
7 a diagnostic mammogram when medically necessary, as
8 determined by a physician licensed to practice medicine in
9 all its branches, advanced practice registered nurse, or
10 physician assistant.
11 A policy subject to this subsection shall not impose a
12deductible, coinsurance, copayment, or any other cost-sharing
13requirement on the coverage provided; except that this sentence
14does not apply to coverage of diagnostic mammograms to the
15extent such coverage would disqualify a high-deductible health
16plan from eligibility for a health savings account pursuant to
17Section 223 of the Internal Revenue Code (26 U.S.C. 223).
18 For purposes of this Section: ,
19 "Diagnostic mammogram" means a mammogram obtained using
20diagnostic mammography.
21 "Diagnostic mammography" means a method of screening that
22is designed to evaluate an abnormality in a breast, including
23an abnormality seen or suspected on a screening mammogram or a
24subjective or objective abnormality otherwise detected in the
25breast.
26 "Low-dose low-dose mammography" means the x-ray

SB0162 Engrossed- 21 -LRB101 07839 SMS 52893 b
1examination of the breast using equipment dedicated
2specifically for mammography, including the x-ray tube,
3filter, compression device, and image receptor, with radiation
4exposure delivery of less than 1 rad per breast for 2 views of
5an average size breast. The term also includes digital
6mammography and includes breast tomosynthesis.
7 "Breast As used in this Section, the term "breast
8tomosynthesis" means a radiologic procedure that involves the
9acquisition of projection images over the stationary breast to
10produce cross-sectional digital three-dimensional images of
11the breast.
12 If, at any time, the Secretary of the United States
13Department of Health and Human Services, or its successor
14agency, promulgates rules or regulations to be published in the
15Federal Register or publishes a comment in the Federal Register
16or issues an opinion, guidance, or other action that would
17require the State, pursuant to any provision of the Patient
18Protection and Affordable Care Act (Public Law 111-148),
19including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
20successor provision, to defray the cost of any coverage for
21breast tomosynthesis outlined in this subsection, then the
22requirement that an insurer cover breast tomosynthesis is
23inoperative other than any such coverage authorized under
24Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
25the State shall not assume any obligation for the cost of
26coverage for breast tomosynthesis set forth in this subsection.

SB0162 Engrossed- 22 -LRB101 07839 SMS 52893 b
1 (a-5) Coverage as described in subsection (a) shall be
2provided at no cost to the enrollee and shall not be applied to
3an annual or lifetime maximum benefit.
4 (b) No contract or evidence of coverage issued by a health
5maintenance organization that provides for the surgical
6procedure known as a mastectomy shall be issued, amended,
7delivered, or renewed in this State on or after the effective
8date of this amendatory Act of the 92nd General Assembly unless
9that coverage also provides for prosthetic devices or
10reconstructive surgery incident to the mastectomy, providing
11that the mastectomy is performed after the effective date of
12this amendatory Act. Coverage for breast reconstruction in
13connection with a mastectomy shall include:
14 (1) reconstruction of the breast upon which the
15 mastectomy has been performed;
16 (2) surgery and reconstruction of the other breast to
17 produce a symmetrical appearance; and
18 (3) prostheses and treatment for physical
19 complications at all stages of mastectomy, including
20 lymphedemas.
21Care shall be determined in consultation with the attending
22physician and the patient. The offered coverage for prosthetic
23devices and reconstructive surgery shall be subject to the
24deductible and coinsurance conditions applied to the
25mastectomy and all other terms and conditions applicable to
26other benefits. When a mastectomy is performed and there is no

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1evidence of malignancy, then the offered coverage may be
2limited to the provision of prosthetic devices and
3reconstructive surgery to within 2 years after the date of the
4mastectomy. As used in this Section, "mastectomy" means the
5removal of all or part of the breast for medically necessary
6reasons, as determined by a licensed physician.
7 Written notice of the availability of coverage under this
8Section shall be delivered to the enrollee upon enrollment and
9annually thereafter. A health maintenance organization may not
10deny to an enrollee eligibility, or continued eligibility, to
11enroll or to renew coverage under the terms of the plan solely
12for the purpose of avoiding the requirements of this Section. A
13health maintenance organization may not penalize or reduce or
14limit the reimbursement of an attending provider or provide
15incentives (monetary or otherwise) to an attending provider to
16induce the provider to provide care to an insured in a manner
17inconsistent with this Section.
18 (c) Rulemaking authority to implement this amendatory Act
19of the 95th General Assembly, if any, is conditioned on the
20rules being adopted in accordance with all provisions of the
21Illinois Administrative Procedure Act and all rules and
22procedures of the Joint Committee on Administrative Rules; any
23purported rule not so adopted, for whatever reason, is
24unauthorized.
25(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
26effective date of P.A. 99-407); 99-588, eff. 7-20-16; 100-395,

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1eff. 1-1-18.)
2 Section 25. The Illinois Public Aid Code is amended by
3changing Section 5-5 as follows:
4 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
5 Sec. 5-5. Medical services. The Illinois Department, by
6rule, shall determine the quantity and quality of and the rate
7of reimbursement for the medical assistance for which payment
8will be authorized, and the medical services to be provided,
9which may include all or part of the following: (1) inpatient
10hospital services; (2) outpatient hospital services; (3) other
11laboratory and X-ray services; (4) skilled nursing home
12services; (5) physicians' services whether furnished in the
13office, the patient's home, a hospital, a skilled nursing home,
14or elsewhere; (6) medical care, or any other type of remedial
15care furnished by licensed practitioners; (7) home health care
16services; (8) private duty nursing service; (9) clinic
17services; (10) dental services, including prevention and
18treatment of periodontal disease and dental caries disease for
19pregnant women, provided by an individual licensed to practice
20dentistry or dental surgery; for purposes of this item (10),
21"dental services" means diagnostic, preventive, or corrective
22procedures provided by or under the supervision of a dentist in
23the practice of his or her profession; (11) physical therapy
24and related services; (12) prescribed drugs, dentures, and

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

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1for healing.
2 Notwithstanding any other provision of this Section, a
3comprehensive tobacco use cessation program that includes
4purchasing prescription drugs or prescription medical devices
5approved by the Food and Drug Administration shall be covered
6under the medical assistance program under this Article for
7persons who are otherwise eligible for assistance under this
8Article.
9 Notwithstanding any other provision of this Code,
10reproductive health care that is otherwise legal in Illinois
11shall be covered under the medical assistance program for
12persons who are otherwise eligible for medical assistance under
13this Article.
14 Notwithstanding any other provision of this Code, the
15Illinois Department may not require, as a condition of payment
16for any laboratory test authorized under this Article, that a
17physician's handwritten signature appear on the laboratory
18test order form. The Illinois Department may, however, impose
19other appropriate requirements regarding laboratory test order
20documentation.
21 Upon receipt of federal approval of an amendment to the
22Illinois Title XIX State Plan for this purpose, the Department
23shall authorize the Chicago Public Schools (CPS) to procure a
24vendor or vendors to manufacture eyeglasses for individuals
25enrolled in a school within the CPS system. CPS shall ensure
26that its vendor or vendors are enrolled as providers in the

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1medical assistance program and in any capitated Medicaid
2managed care entity (MCE) serving individuals enrolled in a
3school within the CPS system. Under any contract procured under
4this provision, the vendor or vendors must serve only
5individuals enrolled in a school within the CPS system. Claims
6for services provided by CPS's vendor or vendors to recipients
7of benefits in the medical assistance program under this Code,
8the Children's Health Insurance Program, or the Covering ALL
9KIDS Health Insurance Program shall be submitted to the
10Department or the MCE in which the individual is enrolled for
11payment and shall be reimbursed at the Department's or the
12MCE's established rates or rate methodologies for eyeglasses.
13 On and after July 1, 2012, the Department of Healthcare and
14Family Services may provide the following services to persons
15eligible for assistance under this Article who are
16participating in education, training or employment programs
17operated by the Department of Human Services as successor to
18the Department of Public Aid:
19 (1) dental services provided by or under the
20 supervision of a dentist; and
21 (2) eyeglasses prescribed by a physician skilled in the
22 diseases of the eye, or by an optometrist, whichever the
23 person may select.
24 On and after July 1, 2018, the Department of Healthcare and
25Family Services shall provide dental services to any adult who
26is otherwise eligible for assistance under the medical

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1assistance program. As used in this paragraph, "dental
2services" means diagnostic, preventative, restorative, or
3corrective procedures, including procedures and services for
4the prevention and treatment of periodontal disease and dental
5caries disease, provided by an individual who is licensed to
6practice dentistry or dental surgery or who is under the
7supervision of a dentist in the practice of his or her
8profession.
9 On and after July 1, 2018, targeted dental services, as set
10forth in Exhibit D of the Consent Decree entered by the United
11States District Court for the Northern District of Illinois,
12Eastern Division, in the matter of Memisovski v. Maram, Case
13No. 92 C 1982, that are provided to adults under the medical
14assistance program shall be established at no less than the
15rates set forth in the "New Rate" column in Exhibit D of the
16Consent Decree for targeted dental services that are provided
17to persons under the age of 18 under the medical assistance
18program.
19 Notwithstanding any other provision of this Code and
20subject to federal approval, the Department may adopt rules to
21allow a dentist who is volunteering his or her service at no
22cost to render dental services through an enrolled
23not-for-profit health clinic without the dentist personally
24enrolling as a participating provider in the medical assistance
25program. A not-for-profit health clinic shall include a public
26health clinic or Federally Qualified Health Center or other

SB0162 Engrossed- 29 -LRB101 07839 SMS 52893 b
1enrolled provider, as determined by the Department, through
2which dental services covered under this Section are performed.
3The Department shall establish a process for payment of claims
4for reimbursement for covered dental services rendered under
5this provision.
6 The Illinois Department, by rule, may distinguish and
7classify the medical services to be provided only in accordance
8with the classes of persons designated in Section 5-2.
9 The Department of Healthcare and Family Services must
10provide coverage and reimbursement for amino acid-based
11elemental formulas, regardless of delivery method, for the
12diagnosis and treatment of (i) eosinophilic disorders and (ii)
13short bowel syndrome when the prescribing physician has issued
14a written order stating that the amino acid-based elemental
15formula is medically necessary.
16 The Illinois Department shall authorize the provision of,
17and shall authorize payment for, screening by low-dose
18mammography for the presence of occult breast cancer for women
1935 years of age or older who are eligible for medical
20assistance under this Article, as follows:
21 (A) A baseline mammogram for women 35 to 39 years of
22 age.
23 (B) An annual mammogram for women 40 years of age or
24 older.
25 (C) A mammogram at the age and intervals considered
26 medically necessary by the woman's health care provider for

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1 women under 40 years of age and having a family history of
2 breast cancer, prior personal history of breast cancer,
3 positive genetic testing, or other risk factors.
4 (D) A comprehensive ultrasound screening and MRI of an
5 entire breast or breasts if a mammogram demonstrates
6 heterogeneous or dense breast tissue or , when medically
7 necessary as determined by a physician licensed to practice
8 medicine in all of its branches.
9 (E) A screening MRI when medically necessary, as
10 determined by a physician licensed to practice medicine in
11 all of its branches.
12 (F) A diagnostic mammogram when medically necessary,
13 as determined by a physician licensed to practice medicine
14 in all its branches, advanced practice registered nurse, or
15 physician assistant.
16The Department shall not impose a deductible, coinsurance,
17copayment, or any other cost-sharing requirement on the
18coverage provided under this paragraph; except that this
19sentence does not apply to coverage of diagnostic mammograms to
20the extent such coverage would disqualify a high-deductible
21health plan from eligibility for a health savings account
22pursuant to Section 223 of the Internal Revenue Code (26 U.S.C.
23223).
24 All screenings shall include a physical breast exam,
25instruction on self-examination and information regarding the
26frequency of self-examination and its value as a preventative

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1tool.
2 For purposes of this Section: ,
3 "Diagnostic mammogram" means a mammogram obtained using
4diagnostic mammography.
5 "Diagnostic mammography" means a method of screening that
6is designed to evaluate an abnormality in a breast, including
7an abnormality seen or suspected on a screening mammogram or a
8subjective or objective abnormality otherwise detected in the
9breast.
10 "Low-dose low-dose mammography" means the x-ray
11examination of the breast using equipment dedicated
12specifically for mammography, including the x-ray tube,
13filter, compression device, and image receptor, with an average
14radiation exposure delivery of less than one rad per breast for
152 views of an average size breast. The term also includes
16digital mammography and includes breast tomosynthesis.
17 "Breast 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.
22 If, at any time, the Secretary of the United States
23Department of Health and Human Services, or its successor
24agency, promulgates rules or regulations to be published in the
25Federal Register or publishes a comment in the Federal Register
26or issues an opinion, guidance, or other action that would

SB0162 Engrossed- 32 -LRB101 07839 SMS 52893 b
1require the State, pursuant to any provision of the Patient
2Protection and Affordable Care Act (Public Law 111-148),
3including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
4successor provision, to defray the cost of any coverage for
5breast tomosynthesis outlined in this paragraph, then the
6requirement that an insurer cover breast tomosynthesis is
7inoperative other than any such coverage authorized under
8Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
9the State shall not assume any obligation for the cost of
10coverage for breast tomosynthesis set forth in this paragraph.
11 On and after January 1, 2016, the Department shall ensure
12that all networks of care for adult clients of the Department
13include access to at least one breast imaging Center of Imaging
14Excellence as certified by the American College of Radiology.
15 On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall be
17reimbursed for screening and diagnostic mammography at the same
18rate as the Medicare program's rates, including the increased
19reimbursement for digital mammography.
20 The Department shall convene an expert panel including
21representatives of hospitals, free-standing mammography
22facilities, and doctors, including radiologists, to establish
23quality standards for mammography.
24 On and after January 1, 2017, providers participating in a
25breast cancer treatment quality improvement program approved
26by the Department shall be reimbursed for breast cancer

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

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1primary care providers with respect to their female patients
2over age 40 receiving an annual mammogram. This performance
3goal shall be used to provide additional reimbursement in the
4form of a quality performance bonus to primary care providers
5who meet that goal.
6 The Department shall devise a means of case-managing or
7patient navigation for beneficiaries diagnosed with breast
8cancer. This program shall initially operate as a pilot program
9in areas of the State with the highest incidence of mortality
10related to breast cancer. At least one pilot program site shall
11be in the metropolitan Chicago area and at least one site shall
12be outside the metropolitan Chicago area. On or after July 1,
132016, the pilot program shall be expanded to include one site
14in western Illinois, one site in southern Illinois, one site in
15central Illinois, and 4 sites within metropolitan Chicago. An
16evaluation of the pilot program shall be carried out measuring
17health outcomes and cost of care for those served by the pilot
18program compared to similarly situated patients who are not
19served by the pilot program.
20 The Department shall require all networks of care to
21develop a means either internally or by contract with experts
22in navigation and community outreach to navigate cancer
23patients to comprehensive care in a timely fashion. The
24Department shall require all networks of care to include access
25for patients diagnosed with cancer to at least one academic
26commission on cancer-accredited cancer program as an

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

SB0162 Engrossed- 36 -LRB101 07839 SMS 52893 b
1medical assistance.
2 Neither the Department of Healthcare and Family Services
3nor the Department of Human Services shall sanction the
4recipient solely on the basis of her substance abuse.
5 The Illinois Department shall establish such regulations
6governing the dispensing of health services under this Article
7as it shall deem appropriate. The Department should seek the
8advice of formal professional advisory committees appointed by
9the Director of the Illinois Department for the purpose of
10providing regular advice on policy and administrative matters,
11information dissemination and educational activities for
12medical and health care providers, and consistency in
13procedures to the Illinois Department.
14 The Illinois Department may develop and contract with
15Partnerships of medical providers to arrange medical services
16for persons eligible under Section 5-2 of this Code.
17Implementation of this Section may be by demonstration projects
18in certain geographic areas. The Partnership shall be
19represented by a sponsor organization. The Department, by rule,
20shall develop qualifications for sponsors of Partnerships.
21Nothing in this Section shall be construed to require that the
22sponsor organization be a medical organization.
23 The sponsor must negotiate formal written contracts with
24medical providers for physician services, inpatient and
25outpatient hospital care, home health services, treatment for
26alcoholism and substance abuse, and other services determined

SB0162 Engrossed- 37 -LRB101 07839 SMS 52893 b
1necessary by the Illinois Department by rule for delivery by
2Partnerships. Physician services must include prenatal and
3obstetrical care. The Illinois Department shall reimburse
4medical services delivered by Partnership providers to clients
5in target areas according to provisions of this Article and the
6Illinois Health Finance Reform Act, except that:
7 (1) Physicians participating in a Partnership and
8 providing certain services, which shall be determined by
9 the Illinois Department, to persons in areas covered by the
10 Partnership may receive an additional surcharge for such
11 services.
12 (2) The Department may elect to consider and negotiate
13 financial incentives to encourage the development of
14 Partnerships and the efficient delivery of medical care.
15 (3) Persons receiving medical services through
16 Partnerships may receive medical and case management
17 services above the level usually offered through the
18 medical assistance program.
19 Medical providers shall be required to meet certain
20qualifications to participate in Partnerships to ensure the
21delivery of high quality medical services. These
22qualifications shall be determined by rule of the Illinois
23Department and may be higher than qualifications for
24participation in the medical assistance program. Partnership
25sponsors may prescribe reasonable additional qualifications
26for participation by medical providers, only with the prior

SB0162 Engrossed- 38 -LRB101 07839 SMS 52893 b
1written approval of the Illinois Department.
2 Nothing in this Section shall limit the free choice of
3practitioners, hospitals, and other providers of medical
4services by clients. In order to ensure patient freedom of
5choice, the Illinois Department shall immediately promulgate
6all rules and take all other necessary actions so that provided
7services may be accessed from therapeutically certified
8optometrists to the full extent of the Illinois Optometric
9Practice Act of 1987 without discriminating between service
10providers.
11 The Department shall apply for a waiver from the United
12States Health Care Financing Administration to allow for the
13implementation of Partnerships under this Section.
14 The Illinois Department shall require health care
15providers to maintain records that document the medical care
16and services provided to recipients of Medical Assistance under
17this Article. Such records must be retained for a period of not
18less than 6 years from the date of service or as provided by
19applicable State law, whichever period is longer, except that
20if an audit is initiated within the required retention period
21then the records must be retained until the audit is completed
22and every exception is resolved. The Illinois Department shall
23require health care providers to make available, when
24authorized by the patient, in writing, the medical records in a
25timely fashion to other health care providers who are treating
26or serving persons eligible for Medical Assistance under this

SB0162 Engrossed- 39 -LRB101 07839 SMS 52893 b
1Article. All dispensers of medical services shall be required
2to maintain and retain business and professional records
3sufficient to fully and accurately document the nature, scope,
4details and receipt of the health care provided to persons
5eligible for medical assistance under this Code, in accordance
6with regulations promulgated by the Illinois Department. The
7rules and regulations shall require that proof of the receipt
8of prescription drugs, dentures, prosthetic devices and
9eyeglasses by eligible persons under this Section accompany
10each claim for reimbursement submitted by the dispenser of such
11medical services. No such claims for reimbursement shall be
12approved for payment by the Illinois Department without such
13proof of receipt, unless the Illinois Department shall have put
14into effect and shall be operating a system of post-payment
15audit and review which shall, on a sampling basis, be deemed
16adequate by the Illinois Department to assure that such drugs,
17dentures, prosthetic devices and eyeglasses for which payment
18is being made are actually being received by eligible
19recipients. Within 90 days after September 16, 1984 (the
20effective date of Public Act 83-1439), the Illinois Department
21shall establish a current list of acquisition costs for all
22prosthetic devices and any other items recognized as medical
23equipment and supplies reimbursable under this Article and
24shall update such list on a quarterly basis, except that the
25acquisition costs of all prescription drugs shall be updated no
26less frequently than every 30 days as required by Section

SB0162 Engrossed- 40 -LRB101 07839 SMS 52893 b
15-5.12.
2 Notwithstanding any other law to the contrary, the Illinois
3Department shall, within 365 days after July 22, 2013 (the
4effective date of Public Act 98-104), establish procedures to
5permit skilled care facilities licensed under the Nursing Home
6Care Act to submit monthly billing claims for reimbursement
7purposes. Following development of these procedures, the
8Department shall, by July 1, 2016, test the viability of the
9new system and implement any necessary operational or
10structural changes to its information technology platforms in
11order to allow for the direct acceptance and payment of nursing
12home claims.
13 Notwithstanding any other law to the contrary, the Illinois
14Department shall, within 365 days after August 15, 2014 (the
15effective date of Public Act 98-963), establish procedures to
16permit ID/DD facilities licensed under the ID/DD Community Care
17Act and MC/DD facilities licensed under the MC/DD Act to submit
18monthly billing claims for reimbursement purposes. Following
19development of these procedures, the Department shall have an
20additional 365 days to test the viability of the new system and
21to ensure that any necessary operational or structural changes
22to its information technology platforms are implemented.
23 The Illinois Department shall require all dispensers of
24medical services, other than an individual practitioner or
25group of practitioners, desiring to participate in the Medical
26Assistance program established under this Article to disclose

SB0162 Engrossed- 41 -LRB101 07839 SMS 52893 b
1all financial, beneficial, ownership, equity, surety or other
2interests in any and all firms, corporations, partnerships,
3associations, business enterprises, joint ventures, agencies,
4institutions or other legal entities providing any form of
5health care services in this State under this Article.
6 The Illinois Department may require that all dispensers of
7medical services desiring to participate in the medical
8assistance program established under this Article disclose,
9under such terms and conditions as the Illinois Department may
10by rule establish, all inquiries from clients and attorneys
11regarding medical bills paid by the Illinois Department, which
12inquiries could indicate potential existence of claims or liens
13for the Illinois Department.
14 Enrollment of a vendor shall be subject to a provisional
15period and shall be conditional for one year. During the period
16of conditional enrollment, the Department may terminate the
17vendor's eligibility to participate in, or may disenroll the
18vendor from, the medical assistance program without cause.
19Unless otherwise specified, such termination of eligibility or
20disenrollment is not subject to the Department's hearing
21process. However, a disenrolled vendor may reapply without
22penalty.
23 The Department has the discretion to limit the conditional
24enrollment period for vendors based upon category of risk of
25the vendor.
26 Prior to enrollment and during the conditional enrollment

SB0162 Engrossed- 42 -LRB101 07839 SMS 52893 b
1period in the medical assistance program, all vendors shall be
2subject to enhanced oversight, screening, and review based on
3the risk of fraud, waste, and abuse that is posed by the
4category of risk of the vendor. The Illinois Department shall
5establish the procedures for oversight, screening, and review,
6which may include, but need not be limited to: criminal and
7financial background checks; fingerprinting; license,
8certification, and authorization verifications; unscheduled or
9unannounced site visits; database checks; prepayment audit
10reviews; audits; payment caps; payment suspensions; and other
11screening as required by federal or State law.
12 The Department shall define or specify the following: (i)
13by provider notice, the "category of risk of the vendor" for
14each type of vendor, which shall take into account the level of
15screening applicable to a particular category of vendor under
16federal law and regulations; (ii) by rule or provider notice,
17the maximum length of the conditional enrollment period for
18each category of risk of the vendor; and (iii) by rule, the
19hearing rights, if any, afforded to a vendor in each category
20of risk of the vendor that is terminated or disenrolled during
21the conditional enrollment period.
22 To be eligible for payment consideration, a vendor's
23payment claim or bill, either as an initial claim or as a
24resubmitted claim following prior rejection, must be received
25by the Illinois Department, or its fiscal intermediary, no
26later than 180 days after the latest date on the claim on which

SB0162 Engrossed- 43 -LRB101 07839 SMS 52893 b
1medical goods or services were provided, with the following
2exceptions:
3 (1) In the case of a provider whose enrollment is in
4 process by the Illinois Department, the 180-day period
5 shall not begin until the date on the written notice from
6 the Illinois Department that the provider enrollment is
7 complete.
8 (2) In the case of errors attributable to the Illinois
9 Department or any of its claims processing intermediaries
10 which result in an inability to receive, process, or
11 adjudicate a claim, the 180-day period shall not begin
12 until the provider has been notified of the error.
13 (3) In the case of a provider for whom the Illinois
14 Department initiates the monthly billing process.
15 (4) In the case of a provider operated by a unit of
16 local government with a population exceeding 3,000,000
17 when local government funds finance federal participation
18 for claims payments.
19 For claims for services rendered during a period for which
20a recipient received retroactive eligibility, claims must be
21filed within 180 days after the Department determines the
22applicant is eligible. For claims for which the Illinois
23Department is not the primary payer, claims must be submitted
24to the Illinois Department within 180 days after the final
25adjudication by the primary payer.
26 In the case of long term care facilities, within 45

SB0162 Engrossed- 44 -LRB101 07839 SMS 52893 b
1calendar days of receipt by the facility of required
2prescreening information, new admissions with associated
3admission documents shall be submitted through the Medical
4Electronic Data Interchange (MEDI) or the Recipient
5Eligibility Verification (REV) System or shall be submitted
6directly to the Department of Human Services using required
7admission forms. Effective September 1, 2014, admission
8documents, including all prescreening information, must be
9submitted through MEDI or REV. Confirmation numbers assigned to
10an accepted transaction shall be retained by a facility to
11verify timely submittal. Once an admission transaction has been
12completed, all resubmitted claims following prior rejection
13are subject to receipt no later than 180 days after the
14admission transaction has been completed.
15 Claims that are not submitted and received in compliance
16with the foregoing requirements shall not be eligible for
17payment under the medical assistance program, and the State
18shall have no liability for payment of those claims.
19 To the extent consistent with applicable information and
20privacy, security, and disclosure laws, State and federal
21agencies and departments shall provide the Illinois Department
22access to confidential and other information and data necessary
23to perform eligibility and payment verifications and other
24Illinois Department functions. This includes, but is not
25limited to: information pertaining to licensure;
26certification; earnings; immigration status; citizenship; wage

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1reporting; unearned and earned income; pension income;
2employment; supplemental security income; social security
3numbers; National Provider Identifier (NPI) numbers; the
4National Practitioner Data Bank (NPDB); program and agency
5exclusions; taxpayer identification numbers; tax delinquency;
6corporate information; and death records.
7 The Illinois Department shall enter into agreements with
8State agencies and departments, and is authorized to enter into
9agreements with federal agencies and departments, under which
10such agencies and departments shall share data necessary for
11medical assistance program integrity functions and oversight.
12The Illinois Department shall develop, in cooperation with
13other State departments and agencies, and in compliance with
14applicable federal laws and regulations, appropriate and
15effective methods to share such data. At a minimum, and to the
16extent necessary to provide data sharing, the Illinois
17Department shall enter into agreements with State agencies and
18departments, and is authorized to enter into agreements with
19federal agencies and departments, including but not limited to:
20the Secretary of State; the Department of Revenue; the
21Department of Public Health; the Department of Human Services;
22and the Department of Financial and Professional Regulation.
23 Beginning in fiscal year 2013, the Illinois Department
24shall set forth a request for information to identify the
25benefits of a pre-payment, post-adjudication, and post-edit
26claims system with the goals of streamlining claims processing

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

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1by rule, exempt certain replacement wheelchair parts from prior
2approval and, for wheelchairs, wheelchair parts, wheelchair
3accessories, and related seating and positioning items,
4determine the wholesale price by methods other than actual
5acquisition costs.
6 The Department shall require, by rule, all providers of
7durable medical equipment to be accredited by an accreditation
8organization approved by the federal Centers for Medicare and
9Medicaid Services and recognized by the Department in order to
10bill the Department for providing durable medical equipment to
11recipients. No later than 15 months after the effective date of
12the rule adopted pursuant to this paragraph, all providers must
13meet the accreditation requirement.
14 In order to promote environmental responsibility, meet the
15needs of recipients and enrollees, and achieve significant cost
16savings, the Department, or a managed care organization under
17contract with the Department, may provide recipients or managed
18care enrollees who have a prescription or Certificate of
19Medical Necessity access to refurbished durable medical
20equipment under this Section (excluding prosthetic and
21orthotic devices as defined in the Orthotics, Prosthetics, and
22Pedorthics Practice Act and complex rehabilitation technology
23products and associated services) through the State's
24assistive technology program's reutilization program, using
25staff with the Assistive Technology Professional (ATP)
26Certification if the refurbished durable medical equipment:

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1(i) is available; (ii) is less expensive, including shipping
2costs, than new durable medical equipment of the same type;
3(iii) is able to withstand at least 3 years of use; (iv) is
4cleaned, disinfected, sterilized, and safe in accordance with
5federal Food and Drug Administration regulations and guidance
6governing the reprocessing of medical devices in health care
7settings; and (v) equally meets the needs of the recipient or
8enrollee. The reutilization program shall confirm that the
9recipient or enrollee is not already in receipt of same or
10similar equipment from another service provider, and that the
11refurbished durable medical equipment equally meets the needs
12of the recipient or enrollee. Nothing in this paragraph shall
13be construed to limit recipient or enrollee choice to obtain
14new durable medical equipment or place any additional prior
15authorization conditions on enrollees of managed care
16organizations.
17 The Department shall execute, relative to the nursing home
18prescreening project, written inter-agency agreements with the
19Department of Human Services and the Department on Aging, to
20effect the following: (i) intake procedures and common
21eligibility criteria for those persons who are receiving
22non-institutional services; and (ii) the establishment and
23development of non-institutional services in areas of the State
24where they are not currently available or are undeveloped; and
25(iii) notwithstanding any other provision of law, subject to
26federal approval, on and after July 1, 2012, an increase in the

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1determination of need (DON) scores from 29 to 37 for applicants
2for institutional and home and community-based long term care;
3if and only if federal approval is not granted, the Department
4may, in conjunction with other affected agencies, implement
5utilization controls or changes in benefit packages to
6effectuate a similar savings amount for this population; and
7(iv) no later than July 1, 2013, minimum level of care
8eligibility criteria for institutional and home and
9community-based long term care; and (v) no later than October
101, 2013, establish procedures to permit long term care
11providers access to eligibility scores for individuals with an
12admission date who are seeking or receiving services from the
13long term care provider. In order to select the minimum level
14of care eligibility criteria, the Governor shall establish a
15workgroup that includes affected agency representatives and
16stakeholders representing the institutional and home and
17community-based long term care interests. This Section shall
18not restrict the Department from implementing lower level of
19care eligibility criteria for community-based services in
20circumstances where federal approval has been granted.
21 The Illinois Department shall develop and operate, in
22cooperation with other State Departments and agencies and in
23compliance with applicable federal laws and regulations,
24appropriate and effective systems of health care evaluation and
25programs for monitoring of utilization of health care services
26and facilities, as it affects persons eligible for medical

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1assistance under this Code.
2 The Illinois Department shall report annually to the
3General Assembly, no later than the second Friday in April of
41979 and each year thereafter, in regard to:
5 (a) actual statistics and trends in utilization of
6 medical services by public aid recipients;
7 (b) actual statistics and trends in the provision of
8 the various medical services by medical vendors;
9 (c) current rate structures and proposed changes in
10 those rate structures for the various medical vendors; and
11 (d) efforts at utilization review and control by the
12 Illinois Department.
13 The period covered by each report shall be the 3 years
14ending on the June 30 prior to the report. The report shall
15include suggested legislation for consideration by the General
16Assembly. The requirement for reporting to the General Assembly
17shall be satisfied by filing copies of the report as required
18by Section 3.1 of the General Assembly Organization Act, and
19filing such additional copies with the State Government Report
20Distribution Center for the General Assembly as is required
21under paragraph (t) of Section 7 of the State Library Act.
22 Rulemaking authority to implement Public Act 95-1045, if
23any, is conditioned on the rules being adopted in accordance
24with all provisions of the Illinois Administrative Procedure
25Act and all rules and procedures of the Joint Committee on
26Administrative Rules; any purported rule not so adopted, for

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1whatever reason, is unauthorized.
2 On and after July 1, 2012, the Department shall reduce any
3rate of reimbursement for services or other payments or alter
4any methodologies authorized by this Code to reduce any rate of
5reimbursement for services or other payments in accordance with
6Section 5-5e.
7 Because kidney transplantation can be an appropriate,
8cost-effective alternative to renal dialysis when medically
9necessary and notwithstanding the provisions of Section 1-11 of
10this Code, beginning October 1, 2014, the Department shall
11cover kidney transplantation for noncitizens with end-stage
12renal disease who are not eligible for comprehensive medical
13benefits, who meet the residency requirements of Section 5-3 of
14this Code, and who would otherwise meet the financial
15requirements of the appropriate class of eligible persons under
16Section 5-2 of this Code. To qualify for coverage of kidney
17transplantation, such person must be receiving emergency renal
18dialysis services covered by the Department. Providers under
19this Section shall be prior approved and certified by the
20Department to perform kidney transplantation and the services
21under this Section shall be limited to services associated with
22kidney transplantation.
23 Notwithstanding any other provision of this Code to the
24contrary, on or after July 1, 2015, all FDA approved forms of
25medication assisted treatment prescribed for the treatment of
26alcohol dependence or treatment of opioid dependence shall be

SB0162 Engrossed- 52 -LRB101 07839 SMS 52893 b
1covered under both fee for service and managed care medical
2assistance programs for persons who are otherwise eligible for
3medical assistance under this Article and shall not be subject
4to any (1) utilization control, other than those established
5under the American Society of Addiction Medicine patient
6placement criteria, (2) prior authorization mandate, or (3)
7lifetime restriction limit mandate.
8 On or after July 1, 2015, opioid antagonists prescribed for
9the treatment of an opioid overdose, including the medication
10product, administration devices, and any pharmacy fees related
11to the dispensing and administration of the opioid antagonist,
12shall be covered under the medical assistance program for
13persons who are otherwise eligible for medical assistance under
14this Article. As used in this Section, "opioid antagonist"
15means a drug that binds to opioid receptors and blocks or
16inhibits the effect of opioids acting on those receptors,
17including, but not limited to, naloxone hydrochloride or any
18other similarly acting drug approved by the U.S. Food and Drug
19Administration.
20 Upon federal approval, the Department shall provide
21coverage and reimbursement for all drugs that are approved for
22marketing by the federal Food and Drug Administration and that
23are recommended by the federal Public Health Service or the
24United States Centers for Disease Control and Prevention for
25pre-exposure prophylaxis and related pre-exposure prophylaxis
26services, including, but not limited to, HIV and sexually

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1transmitted infection screening, treatment for sexually
2transmitted infections, medical monitoring, assorted labs, and
3counseling to reduce the likelihood of HIV infection among
4individuals who are not infected with HIV but who are at high
5risk of HIV infection.
6 A federally qualified health center, as defined in Section
71905(l)(2)(B) of the federal Social Security Act, shall be
8reimbursed by the Department in accordance with the federally
9qualified health center's encounter rate for services provided
10to medical assistance recipients that are performed by a dental
11hygienist, as defined under the Illinois Dental Practice Act,
12working under the general supervision of a dentist and employed
13by a federally qualified health center.
14 Notwithstanding any other provision of this Code, the
15Illinois Department shall authorize licensed dietitian
16nutritionists and certified diabetes educators to counsel
17senior diabetes patients in the senior diabetes patients' homes
18to remove the hurdle of transportation for senior diabetes
19patients to receive treatment.
20(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
2199-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
22the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
2399-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
247-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
25eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
26100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.

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11-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
2100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
312-10-18.)
4 Section 99. Effective date. This Act takes effect upon
5becoming law.
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