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1 AN ACT concerning health.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 1. This Act may be referred to as the Improving
5Health Care for Pregnant and Postpartum Individuals Act.
6 Section 5. The State Employees Group Insurance Act of 1971
7is amended by changing Section 6.11 as follows:
8 (5 ILCS 375/6.11)
9 (Text of Section before amendment by P.A. 100-1170)
10 Sec. 6.11. Required health benefits; Illinois Insurance
11Code requirements. The program of health benefits shall provide
12the post-mastectomy care benefits required to be covered by a
13policy of accident and health insurance under Section 356t of
14the Illinois Insurance Code. The program of health benefits
15shall provide the coverage required under Sections 356g,
16356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
17356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and
19356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code.
20The program of health benefits must comply with Sections
21155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 of the
22Illinois Insurance Code. The Department of Insurance shall

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1enforce the requirements of this Section.
2 Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
9100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
101-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
111-8-19.)
12 (Text of Section after amendment by P.A. 100-1170)
13 Sec. 6.11. Required health benefits; Illinois Insurance
14Code requirements. The program of health benefits shall provide
15the post-mastectomy care benefits required to be covered by a
16policy of accident and health insurance under Section 356t of
17the Illinois Insurance Code. The program of health benefits
18shall provide the coverage required under Sections 356g,
19356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
20356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
21356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29,
22and 356z.32, and 356z.33 of the Illinois Insurance Code. The
23program of health benefits must comply with Sections 155.22a,
24155.37, 355b, 356z.19, 370c, and 370c.1 of the Illinois
25Insurance Code. The Department of Insurance shall enforce the

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1requirements of this Section with respect to Sections 370c and
2370c.1 of the Illinois Insurance Code; all other requirements
3of this Section shall be enforced by the Department of Central
4Management Services.
5 Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
12100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
131-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19;
14100-1170, eff. 6-1-19.)
15 Section 10. The Department of Human Services Act is amended
16by adding Sections 10-23 and 10-24 as follows:
17 (20 ILCS 1305/10-23 new)
18 Sec. 10-23. High-risk pregnant or postpartum women. The
19Department shall expand and update its maternal child health
20programs to serve any pregnant or postpartum woman identified
21as high-risk by her primary care provider or hospital according
22to standards developed by the Department of Public Health under
23Section 3 of the Developmental Disability Prevention Act. The
24services shall be provided by registered nurses, licensed

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1social workers, or other staff with behavioral health or
2medical training, as approved by the Department. The persons
3providing the services may collaborate with other providers,
4including, but not limited to, obstetricians, gynecologists,
5or pediatricians, when providing services to a patient.
6 (20 ILCS 1305/10-24 new)
7 Sec. 10-24. Nurse-Family Partnership Pilot Program.
8Subject to the availability of funds provided for this purpose
9by public or private sources, the Department may, in its
10discretion, establish an evidence-based, voluntary, nurse home
11visitation program that improves the health and well-being of
12low-income, first-time pregnant women and their children. The
13program shall be known as the Nurse-Family Partnership Pilot
14Program and shall include, but not be limited to, the following
15components:
16 (1) Eligibility criteria. Program participants must be
17 first-time pregnant women who have yet to reach the 28th
18 week of pregnancy and who are eligible for medical
19 assistance under Article V of the Illinois Public Aid Code.
20 (2) Maternal health education. Registered nurses shall
21 make home visits to program participants and shall provide
22 education, support, and guidance regarding pregnancy and
23 maternal health, child health and development, parenting,
24 the mother's life course development, and instruction on
25 how to identify and use family and community supports.

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1 (3) Pre-natal and post-natal care. Home visits to
2 program participants shall begin before their 28th week of
3 pregnancy and shall continue on a weekly or biweekly basis
4 until their children reach the age of 2.
5 Section 15. The Department of Public Health Powers and
6Duties Law of the Civil Administrative Code of Illinois is
7amended by adding Section 2310-455 as follows:
8 (20 ILCS 2310/2310-455 new)
9 Sec. 2310-455. High Risk Infant Follow-up. The Department,
10in collaboration with the Department of Human Services, the
11Department of Healthcare and Family Services, and other key
12providers of maternal child health services, shall revise or
13add to the rules of the Maternal and Child Health Services Code
14(77 Ill. Adm. Code 630) that govern the High Risk Infant
15Follow-up, using current scientific and national and State
16outcomes data, to expand existing services to improve both
17maternal and infant outcomes overall and to reduce racial
18disparities in outcomes and services provided. The rules shall
19be revised or adopted on or before June 1, 2021.
20 Section 20. The Counties Code is amended by changing
21Section 5-1069.3 as follows:
22 (55 ILCS 5/5-1069.3)

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1 Sec. 5-1069.3. Required health benefits. If a county,
2including a home rule county, is a self-insurer for purposes of
3providing health insurance coverage for its employees, the
4coverage shall include coverage for the post-mastectomy care
5benefits required to be covered by a policy of accident and
6health insurance under Section 356t and the coverage required
7under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
8356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
9356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and 356z.29,
10356z.32, and 356z.33 of the Illinois Insurance Code. The
11coverage shall comply with Sections 155.22a, 355b, 356z.19, and
12370c of the Illinois Insurance Code. The Department of
13Insurance shall enforce the requirements of this Section. The
14requirement that health benefits be covered as provided in this
15Section is an exclusive power and function of the State and is
16a denial and limitation under Article VII, Section 6,
17subsection (h) of the Illinois Constitution. A home rule county
18to which this Section applies must comply with every provision
19of this Section.
20 Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on
24Administrative Rules; any purported rule not so adopted, for
25whatever reason, is unauthorized.
26(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;

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1100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
21-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
310-3-18.)
4 Section 25. The Illinois Municipal Code is amended by
5changing Section 10-4-2.3 as follows:
6 (65 ILCS 5/10-4-2.3)
7 Sec. 10-4-2.3. Required health benefits. If a
8municipality, including a home rule municipality, is a
9self-insurer for purposes of providing health insurance
10coverage for its employees, the coverage shall include coverage
11for the post-mastectomy care benefits required to be covered by
12a policy of accident and health insurance under Section 356t
13and the coverage required under Sections 356g, 356g.5,
14356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
15356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25,
16and 356z.26, and 356z.29, 356z.32, and 356z.33 of the Illinois
17Insurance Code. The coverage shall comply with Sections
18155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
19Code. The Department of Insurance shall enforce the
20requirements of this Section. The requirement that health
21benefits be covered as provided in this is an exclusive power
22and function of the State and is a denial and limitation under
23Article VII, Section 6, subsection (h) of the Illinois
24Constitution. A home rule municipality to which this Section

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1applies must comply with every provision of this Section.
2 Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17;
9100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff.
101-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
1110-4-18.)
12 Section 30. The School Code is amended by changing Section
1310-22.3f as follows:
14 (105 ILCS 5/10-22.3f)
15 Sec. 10-22.3f. Required health benefits. Insurance
16protection and benefits for employees shall provide the
17post-mastectomy care benefits required to be covered by a
18policy of accident and health insurance under Section 356t and
19the coverage required under Sections 356g, 356g.5, 356g.5-1,
20356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
21356z.13, 356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and
22356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code.
23Insurance policies shall comply with Section 356z.19 of the
24Illinois Insurance Code. The coverage shall comply with

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1Sections 155.22a, 355b, and 370c of the Illinois Insurance
2Code. The Department of Insurance shall enforce the
3requirements of this Section.
4 Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
11100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff.
121-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.)
13 Section 35. The Illinois Insurance Code is amended by
14adding Sections 356z.4a and 356z.33 as follows:
15 (215 ILCS 5/356z.4a new)
16 Sec. 356z.4a. Billing for long-acting reversible
17contraceptives.
18 (a) "Long-acting reversible contraceptive device" means
19any intrauterine device or contraceptive implant.
20 (b) Any group health insurance policy, individual health
21policy, group policy of accident and health insurance, group
22health benefit plan, or qualified health plan that is offered
23through the health insurance marketplace, a small employer
24group health plan, or a large employer group health plan that

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1is amended, delivered, issued, or renewed on or after the
2effective date of this amendatory Act of the 101st General
3Assembly shall allow hospitals separate reimbursement for a
4long-acting reversible contraceptive device provided
5immediately postpartum in the inpatient hospital setting
6before hospital discharge. The payment shall be made in
7addition to a bundled or Diagnostic Related Group reimbursement
8for labor and delivery.
9 (215 ILCS 5/356z.33 new)
10 Sec. 356z.33. Pregnancy and postpartum coverage.
11 (a) A group health insurance policy, individual health
12policy, group policy of accident and health insurance, group
13health benefit plan, qualified health plan that is offered
14through the health insurance marketplace, small employer group
15health plan, or large employer group health plan that is
16amended, delivered, issued, or renewed on or after the
17effective date of this amendatory Act of the 101st General
18Assembly shall provide coverage for medically necessary
19treatment for postpartum complications, including, but not
20limited to, infection, depression, and hemorrhaging, up to one
21year after the woman has given birth to a child as set forth in
22this Section and consistent with other Sections of this Code,
23including, but not limited to, Sections 370c and 370c.1. The
24coverage under this Section shall be subject to other general
25exclusions, limitations, and financial requirements of the

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1policy, including coordination of benefits, participating
2provider requirements, and utilization review of health care
3services, including review of medical necessity, case
4management, experimental and investigational treatments,
5managed care provisions, and other terms and conditions.
6 (b) A group health insurance policy, individual health
7policy, group policy of accident and health insurance, group
8health benefit plan, qualified health plan that is offered
9through the health insurance marketplace, small employer group
10health plan, or large employer group health plan that is
11amended, delivered, issued, or renewed on or after the
12effective date of this amendatory Act of the 101st General
13Assembly shall provide coverage for medically necessary
14treatment of mental, emotional, nervous, or substance use
15disorder or conditions at in-network facilities for a pregnant
16or postpartum woman up to one year after giving birth to a
17child consistent with the requirements set forth in this
18Section and in Sections 370c and 370c.1 of this Code. The
19services for the treatment of mental, emotional, nervous, or
20substance use disorder or condition shall be prescribed or
21ordered by a licensed physician, licensed psychologist,
22licensed psychiatrist, or licensed advanced practice
23registered nurse and provided by licensed health care
24professionals or licensed or certified mental, emotional,
25nervous, or substance use disorder or conditions providers in
26licensed, certified, or otherwise State-approved facilities.

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1 As used in this subsection (b), "provider" includes
2licensed physicians, licensed psychologists, licensed
3psychiatrists, licensed advanced practice registered nurses,
4and licensed and certified mental, emotional, nervous, and
5substance use disorder and conditions providers.
6 Benefits under this subsection (b) shall be as follows:
7 (1) The benefits provided for inpatient and outpatient
8 services for the treatment of mental, emotional, nervous,
9 or substance use disorder or conditions related to
10 pregnancy or postpartum complications shall be provided
11 when determined to be medically necessary consistent with
12 the requirements of Sections 370c and 370c.1 of this Code.
13 The facility or provider shall notify the insurer of both
14 the admission and the initial treatment plan within 48
15 hours after admission or initiation of treatment. Nothing
16 shall prevent an insurer from applying concurrent and
17 post-service utilization review of health care services,
18 including review of medical necessity, case management,
19 experimental and investigational treatments, managed care
20 provisions, and other terms and conditions of the insurance
21 policy.
22 (2) The benefits for the first 48 hours of initiation
23 of services for an inpatient admission,
24 detoxification/withdrawal management program, or a partial
25 hospitalization admission for the treatment of mental,
26 emotional, nervous, or substance use disorder or

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1 conditions related to pregnancy or postpartum
2 complications shall be provided without post-service or
3 concurrent review of medical necessity, as the medical
4 necessity for the first 48 hours of such services shall be
5 determined solely by the covered pregnant or postpartum
6 woman's provider. Nothing shall prevent an insurer from
7 applying concurrent and post-service utilization review,
8 including the review of medical necessity, case
9 management, experimental and investigational treatments,
10 managed care provisions, and other terms and conditions of
11 the insurance policy of any inpatient admission,
12 detoxification/withdrawal management program admission, or
13 a partial hospitalization admission services for the
14 treatment of mental, emotional, nervous, or substance use
15 disorder or conditions related to pregnancy or postpartum
16 complications received 48 hours after the initiation of
17 such services. If an insurer determines that the services
18 are no longer medically necessary, then the covered person
19 shall have the right to external review pursuant to the
20 requirements of the Health Carrier External Review Act.
21 (3) If an insurer determines that continued inpatient
22 care, detoxification/withdrawal management, partial
23 hospitalization, intensive outpatient treatment, or
24 outpatient treatment in a facility is no longer medically
25 necessary, the insurer shall, within 24 hours, provide
26 written notice to the covered pregnant or postpartum woman

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1 and the covered pregnant or postpartum woman's provider of
2 its decision and the right to file an expedited internal
3 appeal of the determination. The insurer shall review and
4 make a determination with respect to the internal appeal
5 within 24 hours and communicate such determination to the
6 covered pregnant or postpartum woman and the covered
7 pregnant or postpartum woman's provider. If the
8 determination is to uphold the denial, the covered pregnant
9 or postpartum woman and the covered pregnant or postpartum
10 woman's provider have the right to file an expedited
11 external appeal. An independent utilization review
12 organization shall make a determination within 72 hours. If
13 the insurer's determination is upheld and it is determined
14 continued inpatient care, detoxification/withdrawal
15 management, partial hospitalization, intensive outpatient
16 treatment, or outpatient treatment is not medically
17 necessary, the insurer shall remain responsible to provide
18 benefits for the inpatient care, detoxification/withdrawal
19 management, partial hospitalization, intensive outpatient
20 treatment, or outpatient treatment through the day
21 following the date the determination is made and the
22 covered pregnant or postpartum woman shall only be
23 responsible for any applicable copayment, deductible, and
24 coinsurance for the stay through that date as applicable
25 under the policy. The covered pregnant or postpartum woman
26 shall not be discharged or released from the inpatient

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1 facility, detoxification/withdrawal management, partial
2 hospitalization, intensive outpatient treatment, or
3 outpatient treatment until all internal appeals and
4 independent utilization review organization appeals are
5 exhausted. A decision to reverse an adverse determination
6 shall comply with the Health Carrier External Review Act.
7 (4) Except as otherwise stated in this subsection (b),
8 the benefits and cost-sharing shall be provided to the same
9 extent as for any other medical condition covered under the
10 policy.
11 (5) The benefits required by this subsection (b) are to
12 be provided to all covered pregnant or postpartum women
13 with a diagnosis of mental, emotional, nervous, or
14 substance use disorder or conditions. The presence of
15 additional related or unrelated diagnoses shall not be a
16 basis to reduce or deny the benefits required by this
17 subsection (b).
18 (c) A group health insurance policy, individual health
19policy, group policy of accident and health insurance, group
20health benefit plan, qualified health plan that is offered
21through the health insurance marketplace, small employer group
22health plan, or large employer group health plan that is
23amended, delivered, issued, executed, or renewed in this State
24or approved for issuance or renewal in this State on or after
25the effective date of this amendatory Act of the 101st General
26Assembly shall provide coverage for case management and

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1outreach for a postpartum woman that had a high-risk pregnancy.
2The coverage under this subsection (c) shall take into
3consideration the cultural differences of the covered
4postpartum woman in case coordination. As used in this
5subsection (c), "high-risk pregnancy" means a pregnancy in
6which the mother or baby is at increased risk for poor health
7or complications during pregnancy or childbirth.
8 Section 40. The Health Maintenance Organization Act is
9amended by changing Section 5-3 as follows:
10 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
11 Sec. 5-3. Insurance Code provisions.
12 (a) Health Maintenance Organizations shall be subject to
13the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
14141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
15154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
16355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
17356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
18356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
19356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33,
20364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d,
21368e, 370c, 370c.1, 401, 401.1, 402, 403, 403A, 408, 408.2,
22409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
23Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
24XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.

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1 (b) For purposes of the Illinois Insurance Code, except for
2Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
3Maintenance Organizations in the following categories are
4deemed to be "domestic companies":
5 (1) a corporation authorized under the Dental Service
6 Plan Act or the Voluntary Health Services Plans Act;
7 (2) a corporation organized under the laws of this
8 State; or
9 (3) a corporation organized under the laws of another
10 state, 30% or more of the enrollees of which are residents
11 of this State, except a corporation subject to
12 substantially the same requirements in its state of
13 organization as is a "domestic company" under Article VIII
14 1/2 of the Illinois Insurance Code.
15 (c) In considering the merger, consolidation, or other
16acquisition of control of a Health Maintenance Organization
17pursuant to Article VIII 1/2 of the Illinois Insurance Code,
18 (1) the Director shall give primary consideration to
19 the continuation of benefits to enrollees and the financial
20 conditions of the acquired Health Maintenance Organization
21 after the merger, consolidation, or other acquisition of
22 control takes effect;
23 (2)(i) the criteria specified in subsection (1)(b) of
24 Section 131.8 of the Illinois Insurance Code shall not
25 apply and (ii) the Director, in making his determination
26 with respect to the merger, consolidation, or other

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1 acquisition of control, need not take into account the
2 effect on competition of the merger, consolidation, or
3 other acquisition of control;
4 (3) the Director shall have the power to require the
5 following information:
6 (A) certification by an independent actuary of the
7 adequacy of the reserves of the Health Maintenance
8 Organization sought to be acquired;
9 (B) pro forma financial statements reflecting the
10 combined balance sheets of the acquiring company and
11 the Health Maintenance Organization sought to be
12 acquired as of the end of the preceding year and as of
13 a date 90 days prior to the acquisition, as well as pro
14 forma financial statements reflecting projected
15 combined operation for a period of 2 years;
16 (C) a pro forma business plan detailing an
17 acquiring party's plans with respect to the operation
18 of the Health Maintenance Organization sought to be
19 acquired for a period of not less than 3 years; and
20 (D) such other information as the Director shall
21 require.
22 (d) The provisions of Article VIII 1/2 of the Illinois
23Insurance Code and this Section 5-3 shall apply to the sale by
24any health maintenance organization of greater than 10% of its
25enrollee population (including without limitation the health
26maintenance organization's right, title, and interest in and to

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1its health care certificates).
2 (e) In considering any management contract or service
3agreement subject to Section 141.1 of the Illinois Insurance
4Code, the Director (i) shall, in addition to the criteria
5specified in Section 141.2 of the Illinois Insurance Code, take
6into account the effect of the management contract or service
7agreement on the continuation of benefits to enrollees and the
8financial condition of the health maintenance organization to
9be managed or serviced, and (ii) need not take into account the
10effect of the management contract or service agreement on
11competition.
12 (f) Except for small employer groups as defined in the
13Small Employer Rating, Renewability and Portability Health
14Insurance Act and except for medicare supplement policies as
15defined in Section 363 of the Illinois Insurance Code, a Health
16Maintenance Organization may by contract agree with a group or
17other enrollment unit to effect refunds or charge additional
18premiums under the following terms and conditions:
19 (i) the amount of, and other terms and conditions with
20 respect to, the refund or additional premium are set forth
21 in the group or enrollment unit contract agreed in advance
22 of the period for which a refund is to be paid or
23 additional premium is to be charged (which period shall not
24 be less than one year); and
25 (ii) the amount of the refund or additional premium
26 shall not exceed 20% of the Health Maintenance

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1 Organization's profitable or unprofitable experience with
2 respect to the group or other enrollment unit for the
3 period (and, for purposes of a refund or additional
4 premium, the profitable or unprofitable experience shall
5 be calculated taking into account a pro rata share of the
6 Health Maintenance Organization's administrative and
7 marketing expenses, but shall not include any refund to be
8 made or additional premium to be paid pursuant to this
9 subsection (f)). The Health Maintenance Organization and
10 the group or enrollment unit may agree that the profitable
11 or unprofitable experience may be calculated taking into
12 account the refund period and the immediately preceding 2
13 plan years.
14 The Health Maintenance Organization shall include a
15statement in the evidence of coverage issued to each enrollee
16describing the possibility of a refund or additional premium,
17and upon request of any group or enrollment unit, provide to
18the group or enrollment unit a description of the method used
19to calculate (1) the Health Maintenance Organization's
20profitable experience with respect to the group or enrollment
21unit and the resulting refund to the group or enrollment unit
22or (2) the Health Maintenance Organization's unprofitable
23experience with respect to the group or enrollment unit and the
24resulting additional premium to be paid by the group or
25enrollment unit.
26 In no event shall the Illinois Health Maintenance

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1Organization Guaranty Association be liable to pay any
2contractual obligation of an insolvent organization to pay any
3refund authorized under this Section.
4 (g) Rulemaking authority to implement Public Act 95-1045,
5if any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17;
11100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff.
128-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised
1310-4-18.)
14 Section 45. The Voluntary Health Services Plans Act is
15amended by changing Section 10 as follows:
16 (215 ILCS 165/10) (from Ch. 32, par. 604)
17 Sec. 10. Application of Insurance Code provisions. Health
18services plan corporations and all persons interested therein
19or dealing therewith shall be subject to the provisions of
20Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
21143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
22356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
23356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
24356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,

SB1909 Engrossed- 22 -LRB101 09278 CPF 54372 b
1356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30,
2356z.32, 356z.33, 364.01, 367.2, 368a, 401, 401.1, 402, 403,
3403A, 408, 408.2, and 412, and paragraphs (7) and (15) of
4Section 367 of the Illinois Insurance Code.
5 Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17;
12100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff.
131-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.)
14 Section 50. The Illinois Public Aid Code is amended by
15changing Sections 5-2, 5-5, and 5-5.24 and by adding Section
165-5.27 as follows:
17 (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
18 Sec. 5-2. Classes of Persons Eligible.
19 Medical assistance under this Article shall be available to
20any of the following classes of persons in respect to whom a
21plan for coverage has been submitted to the Governor by the
22Illinois Department and approved by him. If changes made in
23this Section 5-2 require federal approval, they shall not take
24effect until such approval has been received:

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1 1. Recipients of basic maintenance grants under
2 Articles III and IV.
3 2. Beginning January 1, 2014, persons otherwise
4 eligible for basic maintenance under Article III,
5 excluding any eligibility requirements that are
6 inconsistent with any federal law or federal regulation, as
7 interpreted by the U.S. Department of Health and Human
8 Services, but who fail to qualify thereunder on the basis
9 of need, and who have insufficient income and resources to
10 meet the costs of necessary medical care, including but not
11 limited to the following:
12 (a) All persons otherwise eligible for basic
13 maintenance under Article III but who fail to qualify
14 under that Article on the basis of need and who meet
15 either of the following requirements:
16 (i) their income, as determined by the
17 Illinois Department in accordance with any federal
18 requirements, is equal to or less than 100% of the
19 federal poverty level; or
20 (ii) their income, after the deduction of
21 costs incurred for medical care and for other types
22 of remedial care, is equal to or less than 100% of
23 the federal poverty level.
24 (b) (Blank).
25 3. (Blank).
26 4. Persons not eligible under any of the preceding

SB1909 Engrossed- 24 -LRB101 09278 CPF 54372 b
1 paragraphs who fall sick, are injured, or die, not having
2 sufficient money, property or other resources to meet the
3 costs of necessary medical care or funeral and burial
4 expenses.
5 5.(a) Women during pregnancy and during the 12-month
6 60-day period beginning on the last day of the pregnancy,
7 together with their infants, whose income is at or below
8 200% of the federal poverty level. Until September 30,
9 2019, or sooner if the maintenance of effort requirements
10 under the Patient Protection and Affordable Care Act are
11 eliminated or may be waived before then, women during
12 pregnancy and during the 12-month 60-day period beginning
13 on the last day of the pregnancy, whose countable monthly
14 income, after the deduction of costs incurred for medical
15 care and for other types of remedial care as specified in
16 administrative rule, is equal to or less than the Medical
17 Assistance-No Grant(C) (MANG(C)) Income Standard in effect
18 on April 1, 2013 as set forth in administrative rule.
19 (b) The plan for coverage shall provide ambulatory
20 prenatal care to pregnant women during a presumptive
21 eligibility period and establish an income eligibility
22 standard that is equal to 200% of the federal poverty
23 level, provided that costs incurred for medical care are
24 not taken into account in determining such income
25 eligibility.
26 (c) The Illinois Department may conduct a

SB1909 Engrossed- 25 -LRB101 09278 CPF 54372 b
1 demonstration in at least one county that will provide
2 medical assistance to pregnant women, together with their
3 infants and children up to one year of age, where the
4 income eligibility standard is set up to 185% of the
5 nonfarm income official poverty line, as defined by the
6 federal Office of Management and Budget. The Illinois
7 Department shall seek and obtain necessary authorization
8 provided under federal law to implement such a
9 demonstration. Such demonstration may establish resource
10 standards that are not more restrictive than those
11 established under Article IV of this Code.
12 6. (a) Children younger than age 19 when countable
13 income is at or below 133% of the federal poverty level.
14 Until September 30, 2019, or sooner if the maintenance of
15 effort requirements under the Patient Protection and
16 Affordable Care Act are eliminated or may be waived before
17 then, children younger than age 19 whose countable monthly
18 income, after the deduction of costs incurred for medical
19 care and for other types of remedial care as specified in
20 administrative rule, is equal to or less than the Medical
21 Assistance-No Grant(C) (MANG(C)) Income Standard in effect
22 on April 1, 2013 as set forth in administrative rule.
23 (b) Children and youth who are under temporary custody
24 or guardianship of the Department of Children and Family
25 Services or who receive financial assistance in support of
26 an adoption or guardianship placement from the Department

SB1909 Engrossed- 26 -LRB101 09278 CPF 54372 b
1 of Children and Family Services.
2 7. (Blank).
3 8. As required under federal law, persons who are
4 eligible for Transitional Medical Assistance as a result of
5 an increase in earnings or child or spousal support
6 received. The plan for coverage for this class of persons
7 shall:
8 (a) extend the medical assistance coverage to the
9 extent required by federal law; and
10 (b) offer persons who have initially received 6
11 months of the coverage provided in paragraph (a) above,
12 the option of receiving an additional 6 months of
13 coverage, subject to the following:
14 (i) such coverage shall be pursuant to
15 provisions of the federal Social Security Act;
16 (ii) such coverage shall include all services
17 covered under Illinois' State Medicaid Plan;
18 (iii) no premium shall be charged for such
19 coverage; and
20 (iv) such coverage shall be suspended in the
21 event of a person's failure without good cause to
22 file in a timely fashion reports required for this
23 coverage under the Social Security Act and
24 coverage shall be reinstated upon the filing of
25 such reports if the person remains otherwise
26 eligible.

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1 9. Persons with acquired immunodeficiency syndrome
2 (AIDS) or with AIDS-related conditions with respect to whom
3 there has been a determination that but for home or
4 community-based services such individuals would require
5 the level of care provided in an inpatient hospital,
6 skilled nursing facility or intermediate care facility the
7 cost of which is reimbursed under this Article. Assistance
8 shall be provided to such persons to the maximum extent
9 permitted under Title XIX of the Federal Social Security
10 Act.
11 10. Participants in the long-term care insurance
12 partnership program established under the Illinois
13 Long-Term Care Partnership Program Act who meet the
14 qualifications for protection of resources described in
15 Section 15 of that Act.
16 11. Persons with disabilities who are employed and
17 eligible for Medicaid, pursuant to Section
18 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
19 subject to federal approval, persons with a medically
20 improved disability who are employed and eligible for
21 Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
22 the Social Security Act, as provided by the Illinois
23 Department by rule. In establishing eligibility standards
24 under this paragraph 11, the Department shall, subject to
25 federal approval:
26 (a) set the income eligibility standard at not

SB1909 Engrossed- 28 -LRB101 09278 CPF 54372 b
1 lower than 350% of the federal poverty level;
2 (b) exempt retirement accounts that the person
3 cannot access without penalty before the age of 59 1/2,
4 and medical savings accounts established pursuant to
5 26 U.S.C. 220;
6 (c) allow non-exempt assets up to $25,000 as to
7 those assets accumulated during periods of eligibility
8 under this paragraph 11; and
9 (d) continue to apply subparagraphs (b) and (c) in
10 determining the eligibility of the person under this
11 Article even if the person loses eligibility under this
12 paragraph 11.
13 12. Subject to federal approval, persons who are
14 eligible for medical assistance coverage under applicable
15 provisions of the federal Social Security Act and the
16 federal Breast and Cervical Cancer Prevention and
17 Treatment Act of 2000. Those eligible persons are defined
18 to include, but not be limited to, the following persons:
19 (1) persons who have been screened for breast or
20 cervical cancer under the U.S. Centers for Disease
21 Control and Prevention Breast and Cervical Cancer
22 Program established under Title XV of the federal
23 Public Health Services Act in accordance with the
24 requirements of Section 1504 of that Act as
25 administered by the Illinois Department of Public
26 Health; and

SB1909 Engrossed- 29 -LRB101 09278 CPF 54372 b
1 (2) persons whose screenings under the above
2 program were funded in whole or in part by funds
3 appropriated to the Illinois Department of Public
4 Health for breast or cervical cancer screening.
5 "Medical assistance" under this paragraph 12 shall be
6 identical to the benefits provided under the State's
7 approved plan under Title XIX of the Social Security Act.
8 The Department must request federal approval of the
9 coverage under this paragraph 12 within 30 days after the
10 effective date of this amendatory Act of the 92nd General
11 Assembly.
12 In addition to the persons who are eligible for medical
13 assistance pursuant to subparagraphs (1) and (2) of this
14 paragraph 12, and to be paid from funds appropriated to the
15 Department for its medical programs, any uninsured person
16 as defined by the Department in rules residing in Illinois
17 who is younger than 65 years of age, who has been screened
18 for breast and cervical cancer in accordance with standards
19 and procedures adopted by the Department of Public Health
20 for screening, and who is referred to the Department by the
21 Department of Public Health as being in need of treatment
22 for breast or cervical cancer is eligible for medical
23 assistance benefits that are consistent with the benefits
24 provided to those persons described in subparagraphs (1)
25 and (2). Medical assistance coverage for the persons who
26 are eligible under the preceding sentence is not dependent

SB1909 Engrossed- 30 -LRB101 09278 CPF 54372 b
1 on federal approval, but federal moneys may be used to pay
2 for services provided under that coverage upon federal
3 approval.
4 13. Subject to appropriation and to federal approval,
5 persons living with HIV/AIDS who are not otherwise eligible
6 under this Article and who qualify for services covered
7 under Section 5-5.04 as provided by the Illinois Department
8 by rule.
9 14. Subject to the availability of funds for this
10 purpose, the Department may provide coverage under this
11 Article to persons who reside in Illinois who are not
12 eligible under any of the preceding paragraphs and who meet
13 the income guidelines of paragraph 2(a) of this Section and
14 (i) have an application for asylum pending before the
15 federal Department of Homeland Security or on appeal before
16 a court of competent jurisdiction and are represented
17 either by counsel or by an advocate accredited by the
18 federal Department of Homeland Security and employed by a
19 not-for-profit organization in regard to that application
20 or appeal, or (ii) are receiving services through a
21 federally funded torture treatment center. Medical
22 coverage under this paragraph 14 may be provided for up to
23 24 continuous months from the initial eligibility date so
24 long as an individual continues to satisfy the criteria of
25 this paragraph 14. If an individual has an appeal pending
26 regarding an application for asylum before the Department

SB1909 Engrossed- 31 -LRB101 09278 CPF 54372 b
1 of Homeland Security, eligibility under this paragraph 14
2 may be extended until a final decision is rendered on the
3 appeal. The Department may adopt rules governing the
4 implementation of this paragraph 14.
5 15. Family Care Eligibility.
6 (a) On and after July 1, 2012, a parent or other
7 caretaker relative who is 19 years of age or older when
8 countable income is at or below 133% of the federal
9 poverty level. A person may not spend down to become
10 eligible under this paragraph 15.
11 (b) Eligibility shall be reviewed annually.
12 (c) (Blank).
13 (d) (Blank).
14 (e) (Blank).
15 (f) (Blank).
16 (g) (Blank).
17 (h) (Blank).
18 (i) Following termination of an individual's
19 coverage under this paragraph 15, the individual must
20 be determined eligible before the person can be
21 re-enrolled.
22 16. Subject to appropriation, uninsured persons who
23 are not otherwise eligible under this Section who have been
24 certified and referred by the Department of Public Health
25 as having been screened and found to need diagnostic
26 evaluation or treatment, or both diagnostic evaluation and

SB1909 Engrossed- 32 -LRB101 09278 CPF 54372 b
1 treatment, for prostate or testicular cancer. For the
2 purposes of this paragraph 16, uninsured persons are those
3 who do not have creditable coverage, as defined under the
4 Health Insurance Portability and Accountability Act, or
5 have otherwise exhausted any insurance benefits they may
6 have had, for prostate or testicular cancer diagnostic
7 evaluation or treatment, or both diagnostic evaluation and
8 treatment. To be eligible, a person must furnish a Social
9 Security number. A person's assets are exempt from
10 consideration in determining eligibility under this
11 paragraph 16. Such persons shall be eligible for medical
12 assistance under this paragraph 16 for so long as they need
13 treatment for the cancer. A person shall be considered to
14 need treatment if, in the opinion of the person's treating
15 physician, the person requires therapy directed toward
16 cure or palliation of prostate or testicular cancer,
17 including recurrent metastatic cancer that is a known or
18 presumed complication of prostate or testicular cancer and
19 complications resulting from the treatment modalities
20 themselves. Persons who require only routine monitoring
21 services are not considered to need treatment. "Medical
22 assistance" under this paragraph 16 shall be identical to
23 the benefits provided under the State's approved plan under
24 Title XIX of the Social Security Act. Notwithstanding any
25 other provision of law, the Department (i) does not have a
26 claim against the estate of a deceased recipient of

SB1909 Engrossed- 33 -LRB101 09278 CPF 54372 b
1 services under this paragraph 16 and (ii) does not have a
2 lien against any homestead property or other legal or
3 equitable real property interest owned by a recipient of
4 services under this paragraph 16.
5 17. Persons who, pursuant to a waiver approved by the
6 Secretary of the U.S. Department of Health and Human
7 Services, are eligible for medical assistance under Title
8 XIX or XXI of the federal Social Security Act.
9 Notwithstanding any other provision of this Code and
10 consistent with the terms of the approved waiver, the
11 Illinois Department, may by rule:
12 (a) Limit the geographic areas in which the waiver
13 program operates.
14 (b) Determine the scope, quantity, duration, and
15 quality, and the rate and method of reimbursement, of
16 the medical services to be provided, which may differ
17 from those for other classes of persons eligible for
18 assistance under this Article.
19 (c) Restrict the persons' freedom in choice of
20 providers.
21 18. Beginning January 1, 2014, persons aged 19 or
22 older, but younger than 65, who are not otherwise eligible
23 for medical assistance under this Section 5-2, who qualify
24 for medical assistance pursuant to 42 U.S.C.
25 1396a(a)(10)(A)(i)(VIII) and applicable federal
26 regulations, and who have income at or below 133% of the

SB1909 Engrossed- 34 -LRB101 09278 CPF 54372 b
1 federal poverty level plus 5% for the applicable family
2 size as determined pursuant to 42 U.S.C. 1396a(e)(14) and
3 applicable federal regulations. Persons eligible for
4 medical assistance under this paragraph 18 shall receive
5 coverage for the Health Benefits Service Package as that
6 term is defined in subsection (m) of Section 5-1.1 of this
7 Code. If Illinois' federal medical assistance percentage
8 (FMAP) is reduced below 90% for persons eligible for
9 medical assistance under this paragraph 18, eligibility
10 under this paragraph 18 shall cease no later than the end
11 of the third month following the month in which the
12 reduction in FMAP takes effect.
13 19. Beginning January 1, 2014, as required under 42
14 U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18
15 and younger than age 26 who are not otherwise eligible for
16 medical assistance under paragraphs (1) through (17) of
17 this Section who (i) were in foster care under the
18 responsibility of the State on the date of attaining age 18
19 or on the date of attaining age 21 when a court has
20 continued wardship for good cause as provided in Section
21 2-31 of the Juvenile Court Act of 1987 and (ii) received
22 medical assistance under the Illinois Title XIX State Plan
23 or waiver of such plan while in foster care.
24 20. Beginning January 1, 2018, persons who are
25 foreign-born victims of human trafficking, torture, or
26 other serious crimes as defined in Section 2-19 of this

SB1909 Engrossed- 35 -LRB101 09278 CPF 54372 b
1 Code and their derivative family members if such persons:
2 (i) reside in Illinois; (ii) are not eligible under any of
3 the preceding paragraphs; (iii) meet the income guidelines
4 of subparagraph (a) of paragraph 2; and (iv) meet the
5 nonfinancial eligibility requirements of Sections 16-2,
6 16-3, and 16-5 of this Code. The Department may extend
7 medical assistance for persons who are foreign-born
8 victims of human trafficking, torture, or other serious
9 crimes whose medical assistance would be terminated
10 pursuant to subsection (b) of Section 16-5 if the
11 Department determines that the person, during the year of
12 initial eligibility (1) experienced a health crisis, (2)
13 has been unable, after reasonable attempts, to obtain
14 necessary information from a third party, or (3) has other
15 extenuating circumstances that prevented the person from
16 completing his or her application for status. The
17 Department may adopt any rules necessary to implement the
18 provisions of this paragraph.
19 In implementing the provisions of Public Act 96-20, the
20Department is authorized to adopt only those rules necessary,
21including emergency rules. Nothing in Public Act 96-20 permits
22the Department to adopt rules or issue a decision that expands
23eligibility for the FamilyCare Program to a person whose income
24exceeds 185% of the Federal Poverty Level as determined from
25time to time by the U.S. Department of Health and Human
26Services, unless the Department is provided with express

SB1909 Engrossed- 36 -LRB101 09278 CPF 54372 b
1statutory authority.
2 The eligibility of any such person for medical assistance
3under this Article is not affected by the payment of any grant
4under the Senior Citizens and Persons with Disabilities
5Property Tax Relief Act or any distributions or items of income
6described under subparagraph (X) of paragraph (2) of subsection
7(a) of Section 203 of the Illinois Income Tax Act.
8 The Department shall by rule establish the amounts of
9assets to be disregarded in determining eligibility for medical
10assistance, which shall at a minimum equal the amounts to be
11disregarded under the Federal Supplemental Security Income
12Program. The amount of assets of a single person to be
13disregarded shall not be less than $2,000, and the amount of
14assets of a married couple to be disregarded shall not be less
15than $3,000.
16 To the extent permitted under federal law, any person found
17guilty of a second violation of Article VIIIA shall be
18ineligible for medical assistance under this Article, as
19provided in Section 8A-8.
20 The eligibility of any person for medical assistance under
21this Article shall not be affected by the receipt by the person
22of donations or benefits from fundraisers held for the person
23in cases of serious illness, as long as neither the person nor
24members of the person's family have actual control over the
25donations or benefits or the disbursement of the donations or
26benefits.

SB1909 Engrossed- 37 -LRB101 09278 CPF 54372 b
1 Notwithstanding any other provision of this Code, if the
2United States Supreme Court holds Title II, Subtitle A, Section
32001(a) of Public Law 111-148 to be unconstitutional, or if a
4holding of Public Law 111-148 makes Medicaid eligibility
5allowed under Section 2001(a) inoperable, the State or a unit
6of local government shall be prohibited from enrolling
7individuals in the Medical Assistance Program as the result of
8federal approval of a State Medicaid waiver on or after the
9effective date of this amendatory Act of the 97th General
10Assembly, and any individuals enrolled in the Medical
11Assistance Program pursuant to eligibility permitted as a
12result of such a State Medicaid waiver shall become immediately
13ineligible.
14 Notwithstanding any other provision of this Code, if an Act
15of Congress that becomes a Public Law eliminates Section
162001(a) of Public Law 111-148, the State or a unit of local
17government shall be prohibited from enrolling individuals in
18the Medical Assistance Program as the result of federal
19approval of a State Medicaid waiver on or after the effective
20date of this amendatory Act of the 97th General Assembly, and
21any individuals enrolled in the Medical Assistance Program
22pursuant to eligibility permitted as a result of such a State
23Medicaid waiver shall become immediately ineligible.
24 Effective October 1, 2013, the determination of
25eligibility of persons who qualify under paragraphs 5, 6, 8,
2615, 17, and 18 of this Section shall comply with the

SB1909 Engrossed- 38 -LRB101 09278 CPF 54372 b
1requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
2regulations.
3 The Department of Healthcare and Family Services, the
4Department of Human Services, and the Illinois health insurance
5marketplace shall work cooperatively to assist persons who
6would otherwise lose health benefits as a result of changes
7made under this amendatory Act of the 98th General Assembly to
8transition to other health insurance coverage.
9(Source: P.A. 98-104, eff. 7-22-13; 98-463, eff. 8-16-13;
1099-143, eff. 7-27-15; 99-870, eff. 8-22-16.)
11 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
12 Sec. 5-5. Medical services. The Illinois Department, by
13rule, shall determine the quantity and quality of and the rate
14of reimbursement for the medical assistance for which payment
15will be authorized, and the medical services to be provided,
16which may include all or part of the following: (1) inpatient
17hospital services; (2) outpatient hospital services; (3) other
18laboratory and X-ray services; (4) skilled nursing home
19services; (5) physicians' services whether furnished in the
20office, the patient's home, a hospital, a skilled nursing home,
21or elsewhere; (6) medical care, or any other type of remedial
22care furnished by licensed practitioners; (7) home health care
23services; (8) private duty nursing service; (9) clinic
24services; (10) dental services, including prevention and
25treatment of periodontal disease and dental caries disease for

SB1909 Engrossed- 39 -LRB101 09278 CPF 54372 b
1pregnant women, provided by an individual licensed to practice
2dentistry or dental surgery; for purposes of this item (10),
3"dental services" means diagnostic, preventive, or corrective
4procedures provided by or under the supervision of a dentist in
5the practice of his or her profession; (11) physical therapy
6and related services; (12) prescribed drugs, dentures, and
7prosthetic devices; and eyeglasses prescribed by a physician
8skilled in the diseases of the eye, or by an optometrist,
9whichever the person may select; (13) other diagnostic,
10screening, preventive, and rehabilitative services, including
11to ensure that the individual's need for intervention or
12treatment of mental disorders or substance use disorders or
13co-occurring mental health and substance use disorders is
14determined using a uniform screening, assessment, and
15evaluation process inclusive of criteria, for children and
16adults; for purposes of this item (13), a uniform screening,
17assessment, and evaluation process refers to a process that
18includes an appropriate evaluation and, as warranted, a
19referral; "uniform" does not mean the use of a singular
20instrument, tool, or process that all must utilize; (14)
21transportation and such other expenses as may be necessary;
22(15) medical treatment of sexual assault survivors, as defined
23in Section 1a of the Sexual Assault Survivors Emergency
24Treatment Act, for injuries sustained as a result of the sexual
25assault, including examinations and laboratory tests to
26discover evidence which may be used in criminal proceedings

SB1909 Engrossed- 40 -LRB101 09278 CPF 54372 b
1arising from the sexual assault; (16) the diagnosis and
2treatment of sickle cell anemia; and (17) any other medical
3care, and any other type of remedial care recognized under the
4laws of this State. The term "any other type of remedial care"
5shall include nursing care and nursing home service for persons
6who rely on treatment by spiritual means alone through prayer
7for healing.
8 Notwithstanding any other provision of this Section, a
9comprehensive tobacco use cessation program that includes
10purchasing prescription drugs or prescription medical devices
11approved by the Food and Drug Administration shall be covered
12under the medical assistance program under this Article for
13persons who are otherwise eligible for assistance under this
14Article.
15 Notwithstanding any other provision of this Code,
16reproductive health care that is otherwise legal in Illinois
17shall be covered under the medical assistance program for
18persons who are otherwise eligible for medical assistance under
19this Article.
20 Notwithstanding any other provision of this Code, the
21Illinois Department may not require, as a condition of payment
22for any laboratory test authorized under this Article, that a
23physician's handwritten signature appear on the laboratory
24test order form. The Illinois Department may, however, impose
25other appropriate requirements regarding laboratory test order
26documentation.

SB1909 Engrossed- 41 -LRB101 09278 CPF 54372 b
1 Upon receipt of federal approval of an amendment to the
2Illinois Title XIX State Plan for this purpose, the Department
3shall authorize the Chicago Public Schools (CPS) to procure a
4vendor or vendors to manufacture eyeglasses for individuals
5enrolled in a school within the CPS system. CPS shall ensure
6that its vendor or vendors are enrolled as providers in the
7medical assistance program and in any capitated Medicaid
8managed care entity (MCE) serving individuals enrolled in a
9school within the CPS system. Under any contract procured under
10this provision, the vendor or vendors must serve only
11individuals enrolled in a school within the CPS system. Claims
12for services provided by CPS's vendor or vendors to recipients
13of benefits in the medical assistance program under this Code,
14the Children's Health Insurance Program, or the Covering ALL
15KIDS Health Insurance Program shall be submitted to the
16Department or the MCE in which the individual is enrolled for
17payment and shall be reimbursed at the Department's or the
18MCE's established rates or rate methodologies for eyeglasses.
19 On and after July 1, 2012, the Department of Healthcare and
20Family Services may provide the following services to persons
21eligible for assistance under this Article who are
22participating in education, training or employment programs
23operated by the Department of Human Services as successor to
24the Department of Public Aid:
25 (1) dental services provided by or under the
26 supervision of a dentist; and

SB1909 Engrossed- 42 -LRB101 09278 CPF 54372 b
1 (2) eyeglasses prescribed by a physician skilled in the
2 diseases of the eye, or by an optometrist, whichever the
3 person may select.
4 On and after July 1, 2018, the Department of Healthcare and
5Family Services shall provide dental services to any adult who
6is otherwise eligible for assistance under the medical
7assistance program. As used in this paragraph, "dental
8services" means diagnostic, preventative, restorative, or
9corrective procedures, including procedures and services for
10the prevention and treatment of periodontal disease and dental
11caries disease, provided by an individual who is licensed to
12practice dentistry or dental surgery or who is under the
13supervision of a dentist in the practice of his or her
14profession.
15 On and after July 1, 2018, targeted dental services, as set
16forth in Exhibit D of the Consent Decree entered by the United
17States District Court for the Northern District of Illinois,
18Eastern Division, in the matter of Memisovski v. Maram, Case
19No. 92 C 1982, that are provided to adults under the medical
20assistance program shall be established at no less than the
21rates set forth in the "New Rate" column in Exhibit D of the
22Consent Decree for targeted dental services that are provided
23to persons under the age of 18 under the medical assistance
24program.
25 Notwithstanding any other provision of this Code and
26subject to federal approval, the Department may adopt rules to

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1allow a dentist who is volunteering his or her service at no
2cost to render dental services through an enrolled
3not-for-profit health clinic without the dentist personally
4enrolling as a participating provider in the medical assistance
5program. A not-for-profit health clinic shall include a public
6health clinic or Federally Qualified Health Center or other
7enrolled provider, as determined by the Department, through
8which dental services covered under this Section are performed.
9The Department shall establish a process for payment of claims
10for reimbursement for covered dental services rendered under
11this provision.
12 The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in accordance
14with the classes of persons designated in Section 5-2.
15 The Department of Healthcare and Family Services must
16provide coverage and reimbursement for amino acid-based
17elemental formulas, regardless of delivery method, for the
18diagnosis and treatment of (i) eosinophilic disorders and (ii)
19short bowel syndrome when the prescribing physician has issued
20a written order stating that the amino acid-based elemental
21formula is medically necessary.
22 The Illinois Department shall authorize the provision of,
23and shall authorize payment for, screening by low-dose
24mammography for the presence of occult breast cancer for women
2535 years of age or older who are eligible for medical
26assistance under this Article, as follows:

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1 (A) A baseline mammogram for women 35 to 39 years of
2 age.
3 (B) An annual mammogram for women 40 years of age or
4 older.
5 (C) 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 (D) A comprehensive ultrasound screening and MRI of an
11 entire breast or breasts if a mammogram demonstrates
12 heterogeneous or dense breast tissue, when medically
13 necessary as determined by a physician licensed to practice
14 medicine in all of its branches.
15 (E) A screening MRI when medically necessary, as
16 determined by a physician licensed to practice medicine in
17 all of its branches.
18 All screenings shall include a physical breast exam,
19instruction on self-examination and information regarding the
20frequency of self-examination and its value as a preventative
21tool. For purposes of this Section, "low-dose mammography"
22means the x-ray examination of the breast using equipment
23dedicated specifically for mammography, including the x-ray
24tube, filter, compression device, and image receptor, with an
25average radiation exposure delivery of less than one rad per
26breast for 2 views of an average size breast. The term also

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1includes digital mammography and includes breast
2tomosynthesis. As used in this Section, the term "breast
3tomosynthesis" means a radiologic procedure that involves the
4acquisition of projection images over the stationary breast to
5produce cross-sectional digital three-dimensional images of
6the breast. If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in the
9Federal Register or publishes a comment in the Federal Register
10or issues an opinion, guidance, or other action that would
11require the State, pursuant to any provision of the Patient
12Protection and Affordable Care Act (Public Law 111-148),
13including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
14successor provision, to defray the cost of any coverage for
15breast tomosynthesis outlined in this paragraph, then the
16requirement that an insurer cover breast tomosynthesis is
17inoperative other than any such coverage authorized under
18Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
19the State shall not assume any obligation for the cost of
20coverage for breast tomosynthesis set forth in this paragraph.
21 On and after January 1, 2016, the Department shall ensure
22that all networks of care for adult clients of the Department
23include access to at least one breast imaging Center of Imaging
24Excellence as certified by the American College of Radiology.
25 On and after January 1, 2012, providers participating in a
26quality improvement program approved by the Department shall be

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1reimbursed for screening and diagnostic mammography at the same
2rate as the Medicare program's rates, including the increased
3reimbursement for digital mammography.
4 The Department shall convene an expert panel including
5representatives of hospitals, free-standing mammography
6facilities, and doctors, including radiologists, to establish
7quality standards for mammography.
8 On and after January 1, 2017, providers participating in a
9breast cancer treatment quality improvement program approved
10by the Department shall be reimbursed for breast cancer
11treatment at a rate that is no lower than 95% of the Medicare
12program's rates for the data elements included in the breast
13cancer treatment quality program.
14 The Department shall convene an expert panel, including
15representatives of hospitals, free-standing breast cancer
16treatment centers, breast cancer quality organizations, and
17doctors, including breast surgeons, reconstructive breast
18surgeons, oncologists, and primary care providers to establish
19quality standards for breast cancer treatment.
20 Subject to federal approval, the Department shall
21establish a rate methodology for mammography at federally
22qualified health centers and other encounter-rate clinics.
23These clinics or centers may also collaborate with other
24hospital-based mammography facilities. By January 1, 2016, the
25Department shall report to the General Assembly on the status
26of the provision set forth in this paragraph.

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1 The Department shall establish a methodology to remind
2women who are age-appropriate for screening mammography, but
3who have not received a mammogram within the previous 18
4months, of the importance and benefit of screening mammography.
5The Department shall work with experts in breast cancer
6outreach and patient navigation to optimize these reminders and
7shall establish a methodology for evaluating their
8effectiveness and modifying the methodology based on the
9evaluation.
10 The Department shall establish a performance goal for
11primary care providers with respect to their female patients
12over age 40 receiving an annual mammogram. This performance
13goal shall be used to provide additional reimbursement in the
14form of a quality performance bonus to primary care providers
15who meet that goal.
16 The Department shall devise a means of case-managing or
17patient navigation for beneficiaries diagnosed with breast
18cancer. This program shall initially operate as a pilot program
19in areas of the State with the highest incidence of mortality
20related to breast cancer. At least one pilot program site shall
21be in the metropolitan Chicago area and at least one site shall
22be outside the metropolitan Chicago area. On or after July 1,
232016, the pilot program shall be expanded to include one site
24in western Illinois, one site in southern Illinois, one site in
25central Illinois, and 4 sites within metropolitan Chicago. An
26evaluation of the pilot program shall be carried out measuring

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1health outcomes and cost of care for those served by the pilot
2program compared to similarly situated patients who are not
3served by the pilot program.
4 The Department shall require all networks of care to
5develop a means either internally or by contract with experts
6in navigation and community outreach to navigate cancer
7patients to comprehensive care in a timely fashion. The
8Department shall require all networks of care to include access
9for patients diagnosed with cancer to at least one academic
10commission on cancer-accredited cancer program as an
11in-network covered benefit.
12 On or after July 1, 2019, women who are otherwise eligible
13for medical assistance under this Article shall receive
14coverage for doula services by a certified doula during their
15pregnancy and during the 12-month period beginning on the last
16day of their pregnancy. As used in this paragraph, "certified
17doula" means an individual who has received a certification to
18perform doula services from the International Childbirth
19Education Association, the Doulas of North America, the
20Association of Labor Assistants and Childbirth Educators,
21BirthWorks, the Childbirth and Postpartum Professional
22Association, Childbirth International, the International
23Center for Traditional Childbearing, or Commonsense Childbirth
24Inc. As used in this paragraph, "doula services" means
25continuous personal, non-medical emotional and physical
26support throughout labor and birth, and intermittently during

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1the prenatal and postpartum periods.
2 On or after July 1, 2019, women who are otherwise eligible
3for medical assistance under this Article shall receive
4coverage for perinatal depression screenings for the 12-month
5period beginning on the last day of their pregnancy. Medical
6assistance coverage under this paragraph shall be conditioned
7on the use of a screening instrument approved by the
8Department.
9 Any medical or health care provider shall immediately
10recommend, to any pregnant woman who is being provided prenatal
11services and is suspected of having a substance use disorder as
12defined in the Substance Use Disorder Act, referral to a local
13substance use disorder treatment program licensed by the
14Department of Human Services or to a licensed hospital which
15provides substance abuse treatment services. The Department of
16Healthcare and Family Services shall assure coverage for the
17cost of treatment of the drug abuse or addiction for pregnant
18recipients in accordance with the Illinois Medicaid Program in
19conjunction with the Department of Human Services.
20 All medical providers providing medical assistance to
21pregnant women under this Code shall receive information from
22the Department on the availability of services under any
23program providing case management services for addicted women,
24including information on appropriate referrals for other
25social services that may be needed by addicted women in
26addition to treatment for addiction.

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

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

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

SB1909 Engrossed- 53 -LRB101 09278 CPF 54372 b
1if an audit is initiated within the required retention period
2then the records must be retained until the audit is completed
3and every exception is resolved. The Illinois Department shall
4require health care providers to make available, when
5authorized by the patient, in writing, the medical records in a
6timely fashion to other health care providers who are treating
7or serving persons eligible for Medical Assistance under this
8Article. All dispensers of medical services shall be required
9to maintain and retain business and professional records
10sufficient to fully and accurately document the nature, scope,
11details and receipt of the health care provided to persons
12eligible for medical assistance under this Code, in accordance
13with regulations promulgated by the Illinois Department. The
14rules and regulations shall require that proof of the receipt
15of prescription drugs, dentures, prosthetic devices and
16eyeglasses by eligible persons under this Section accompany
17each claim for reimbursement submitted by the dispenser of such
18medical services. No such claims for reimbursement shall be
19approved for payment by the Illinois Department without such
20proof of receipt, unless the Illinois Department shall have put
21into effect and shall be operating a system of post-payment
22audit and review which shall, on a sampling basis, be deemed
23adequate by the Illinois Department to assure that such drugs,
24dentures, prosthetic devices and eyeglasses for which payment
25is being made are actually being received by eligible
26recipients. Within 90 days after September 16, 1984 (the

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1effective date of Public Act 83-1439), the Illinois Department
2shall establish a current list of acquisition costs for all
3prosthetic devices and any other items recognized as medical
4equipment and supplies reimbursable under this Article and
5shall update such list on a quarterly basis, except that the
6acquisition costs of all prescription drugs shall be updated no
7less frequently than every 30 days as required by Section
85-5.12.
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
3penalty.
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

SB1909 Engrossed- 57 -LRB101 09278 CPF 54372 b
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
9exceptions:
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 45
8calendar days of receipt by the facility of required
9prescreening information, new admissions with associated
10admission documents shall be submitted through the Medical
11Electronic Data Interchange (MEDI) or the Recipient
12Eligibility Verification (REV) System or shall be submitted
13directly to the Department of Human Services using required
14admission forms. Effective September 1, 2014, admission
15documents, including all prescreening information, must be
16submitted through MEDI or REV. Confirmation numbers assigned to
17an accepted transaction shall be retained by a facility to
18verify timely submittal. Once an admission transaction has been
19completed, all resubmitted claims following prior rejection
20are subject to receipt no later than 180 days after the
21admission transaction has been completed.
22 Claims that are not submitted and received in compliance
23with the foregoing requirements shall not be eligible for
24payment under the medical assistance program, and the State
25shall have no liability for payment of those claims.
26 To the extent consistent with applicable information and

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1privacy, security, and disclosure laws, State and federal
2agencies and departments shall provide the Illinois Department
3access to confidential and other information and data necessary
4to perform eligibility and payment verifications and other
5Illinois Department functions. This includes, but is not
6limited to: information pertaining to licensure;
7certification; earnings; immigration status; citizenship; wage
8reporting; unearned and earned income; pension income;
9employment; supplemental security income; social security
10numbers; National Provider Identifier (NPI) numbers; the
11National Practitioner Data Bank (NPDB); program and agency
12exclusions; taxpayer identification numbers; tax delinquency;
13corporate information; and death records.
14 The Illinois Department shall enter into agreements with
15State agencies and departments, and is authorized to enter into
16agreements with federal agencies and departments, under which
17such agencies and departments shall share data necessary for
18medical assistance program integrity functions and oversight.
19The Illinois Department shall develop, in cooperation with
20other State departments and agencies, and in compliance with
21applicable federal laws and regulations, appropriate and
22effective methods to share such data. At a minimum, and to the
23extent necessary to provide data sharing, the Illinois
24Department shall enter into agreements with State agencies and
25departments, and is authorized to enter into agreements with
26federal agencies and departments, including but not limited to:

SB1909 Engrossed- 60 -LRB101 09278 CPF 54372 b
1the Secretary of State; the Department of Revenue; the
2Department of Public Health; the Department of Human Services;
3and the Department of Financial and Professional Regulation.
4 Beginning in fiscal year 2013, the Illinois Department
5shall set forth a request for information to identify the
6benefits of a pre-payment, post-adjudication, and post-edit
7claims system with the goals of streamlining claims processing
8and provider reimbursement, reducing the number of pending or
9rejected claims, and helping to ensure a more transparent
10adjudication process through the utilization of: (i) provider
11data verification and provider screening technology; and (ii)
12clinical code editing; and (iii) pre-pay, pre- or
13post-adjudicated predictive modeling with an integrated case
14management system with link analysis. Such a request for
15information shall not be considered as a request for proposal
16or as an obligation on the part of the Illinois Department to
17take any action or acquire any products or services.
18 The Illinois Department shall establish policies,
19procedures, standards and criteria by rule for the acquisition,
20repair and replacement of orthotic and prosthetic devices and
21durable medical equipment. Such rules shall provide, but not be
22limited to, the following services: (1) immediate repair or
23replacement of such devices by recipients; and (2) rental,
24lease, purchase or lease-purchase of durable medical equipment
25in a cost-effective manner, taking into consideration the
26recipient's medical prognosis, the extent of the recipient's

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

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1equipment under this Section (excluding prosthetic and
2orthotic devices as defined in the Orthotics, Prosthetics, and
3Pedorthics Practice Act and complex rehabilitation technology
4products and associated services) through the State's
5assistive technology program's reutilization program, using
6staff with the Assistive Technology Professional (ATP)
7Certification if the refurbished durable medical equipment:
8(i) is available; (ii) is less expensive, including shipping
9costs, than new durable medical equipment of the same type;
10(iii) is able to withstand at least 3 years of use; (iv) is
11cleaned, disinfected, sterilized, and safe in accordance with
12federal Food and Drug Administration regulations and guidance
13governing the reprocessing of medical devices in health care
14settings; and (v) equally meets the needs of the recipient or
15enrollee. The reutilization program shall confirm that the
16recipient or enrollee is not already in receipt of same or
17similar equipment from another service provider, and that the
18refurbished durable medical equipment equally meets the needs
19of the recipient or enrollee. Nothing in this paragraph shall
20be construed to limit recipient or enrollee choice to obtain
21new durable medical equipment or place any additional prior
22authorization conditions on enrollees of managed care
23organizations.
24 The Department shall execute, relative to the nursing home
25prescreening project, written inter-agency agreements with the
26Department of Human Services and the Department on Aging, to

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1effect the following: (i) intake procedures and common
2eligibility criteria for those persons who are receiving
3non-institutional services; and (ii) the establishment and
4development of non-institutional services in areas of the State
5where they are not currently available or are undeveloped; and
6(iii) notwithstanding any other provision of law, subject to
7federal approval, on and after July 1, 2012, an increase in the
8determination of need (DON) scores from 29 to 37 for applicants
9for institutional and home and community-based long term care;
10if and only if federal approval is not granted, the Department
11may, in conjunction with other affected agencies, implement
12utilization controls or changes in benefit packages to
13effectuate a similar savings amount for this population; and
14(iv) no later than July 1, 2013, minimum level of care
15eligibility criteria for institutional and home and
16community-based long term care; and (v) no later than October
171, 2013, establish procedures to permit long term care
18providers access to eligibility scores for individuals with an
19admission date who are seeking or receiving services from the
20long term care provider. In order to select the minimum level
21of care eligibility criteria, the Governor shall establish a
22workgroup that includes affected agency representatives and
23stakeholders representing the institutional and home and
24community-based long term care interests. This Section shall
25not restrict the Department from implementing lower level of
26care eligibility criteria for community-based services in

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1circumstances where federal approval has been granted.
2 The Illinois Department shall develop and operate, in
3cooperation with other State Departments and agencies and in
4compliance with applicable federal laws and regulations,
5appropriate and effective systems of health care evaluation and
6programs for monitoring of utilization of health care services
7and facilities, as it affects persons eligible for medical
8assistance under this Code.
9 The Illinois Department shall report annually to the
10General Assembly, no later than the second Friday in April of
111979 and each year thereafter, in regard to:
12 (a) actual statistics and trends in utilization of
13 medical services by public aid recipients;
14 (b) actual statistics and trends in the provision of
15 the various medical services by medical vendors;
16 (c) current rate structures and proposed changes in
17 those rate structures for the various medical vendors; and
18 (d) efforts at utilization review and control by the
19 Illinois Department.
20 The period covered by each report shall be the 3 years
21ending on the June 30 prior to the report. The report shall
22include suggested legislation for consideration by the General
23Assembly. The requirement for reporting to the General Assembly
24shall be satisfied by filing copies of the report as required
25by Section 3.1 of the General Assembly Organization Act, and
26filing such additional copies with the State Government Report

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

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

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1 Upon federal approval, the Department shall provide
2coverage and reimbursement for all drugs that are approved for
3marketing by the federal Food and Drug Administration and that
4are recommended by the federal Public Health Service or the
5United States Centers for Disease Control and Prevention for
6pre-exposure prophylaxis and related pre-exposure prophylaxis
7services, including, but not limited to, HIV and sexually
8transmitted infection screening, treatment for sexually
9transmitted infections, medical monitoring, assorted labs, and
10counseling to reduce the likelihood of HIV infection among
11individuals who are not infected with HIV but who are at high
12risk of HIV infection.
13 A federally qualified health center, as defined in Section
141905(l)(2)(B) of the federal Social Security Act, shall be
15reimbursed by the Department in accordance with the federally
16qualified health center's encounter rate for services provided
17to medical assistance recipients that are performed by a dental
18hygienist, as defined under the Illinois Dental Practice Act,
19working under the general supervision of a dentist and employed
20by a federally qualified health center.
21 Notwithstanding any other provision of this Code, the
22Illinois Department shall authorize licensed dietitian
23nutritionists and certified diabetes educators to counsel
24senior diabetes patients in the senior diabetes patients' homes
25to remove the hurdle of transportation for senior diabetes
26patients to receive treatment.

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1 The Department shall seek approval of a State Plan
2amendment to expand coverage for family planning services to
3women whose income is at or below 200% of the federal poverty
4level.
5(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
699-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
7the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
899-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
97-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
10eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
11100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
121-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
13100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
1412-10-18.)
15 (305 ILCS 5/5-5.24)
16 Sec. 5-5.24. Prenatal and perinatal care. The Department of
17Healthcare and Family Services may provide reimbursement under
18this Article for all prenatal and perinatal health care
19services that are provided for the purpose of preventing
20low-birthweight infants, reducing the need for neonatal
21intensive care hospital services, and promoting perinatal and
22maternal health. These services may include comprehensive risk
23assessments for pregnant women, women with infants, and
24infants, lactation counseling, nutrition counseling,
25childbirth support, psychosocial counseling, treatment and

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1prevention of periodontal disease, language translation, nurse
2home visitation, and other support services that have been
3proven to improve birth and maternal health outcomes. The
4Department shall maximize the use of preventive prenatal and
5perinatal health care services consistent with federal
6statutes, rules, and regulations. The Department of Public Aid
7(now Department of Healthcare and Family Services) shall
8develop a plan for prenatal and perinatal preventive health
9care and shall present the plan to the General Assembly by
10January 1, 2004. On or before January 1, 2006 and every 2 years
11thereafter, the Department shall report to the General Assembly
12concerning the effectiveness of prenatal and perinatal health
13care services reimbursed under this Section in preventing
14low-birthweight infants and reducing the need for neonatal
15intensive care hospital services. Each such report shall
16include an evaluation of how the ratio of expenditures for
17treating low-birthweight infants compared with the investment
18in promoting healthy births and infants in local community
19areas throughout Illinois relates to healthy infant
20development in those areas.
21 On and after July 1, 2012, the Department shall reduce any
22rate of reimbursement for services or other payments or alter
23any methodologies authorized by this Code to reduce any rate of
24reimbursement for services or other payments in accordance with
25Section 5-5e.
26(Source: P.A. 97-689, eff. 6-14-12.)

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1 Section 55. The Developmental Disability Prevention Act is
2amended by adding Section 11.2 as follows:
3 (410 ILCS 250/11.2 new)
4 Sec. 11.2. Birthing facilities; maternal care
5designations.
6 (a) In this Section, "birthing facility" means: (1) a
7hospital, as defined in the Hospital Licensing Act, with more
8than one licensed obstetric bed or a neonatal intensive care
9unit; (2) a hospital operated by a State university; or (3) a
10birth center, as defined in the Alternative Health Care
11Delivery Act.
12 (b) Every birthing facility shall, at a minimum, have an
13obstetric hemorrhage protocol and conduct a drill or simulation
14of the protocol. Every contracted provider who may encounter a
15pregnant woman shall participate in the drill or simulation on
16a regular basis. The Department shall adopt rules to implement
17this subsection.
18 (c) After holding multiple public hearings with
19representatives from diverse geographical regions and
20professional backgrounds and seeking broad public and
21stakeholder input, the Department shall establish criteria for
22levels of maternal care designations for birthing facilities.
23All hearings shall be open to the public and held at specific
24times and places that are convenient and available to the

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1public. No hearing shall be held on a legal holiday. Public
2notice of hearings shall state the dates, times, and places of
3the hearings. Notice of hearings shall be posted on the
4Department's website and in the Department's main office, and
5minutes from the hearings shall be recorded. The levels of
6maternal care designations developed under this Section shall
7be based upon:
8 (1) the most current published version of the "Levels
9 of Maternal Care" developed by the American Congress of
10 Obstetricians and Gynecologists and the Society for
11 Maternal-Fetal Medicine; and
12 (2) necessary variance when considering the geographic
13 and varied needs of citizens of this State.
14 (d) Nothing in this Section shall be construed in any way
15to modify or expand the licensure of any health care
16professional.
17 (e) Nothing in this Section shall be construed in any way
18to require a patient to be transferred to a different facility.
19 (f) The Department shall adopt rules to implement the
20provisions of this Section no later than June 1, 2021. These
21rules shall be limited to those necessary for the establishment
22of levels of maternal care designations for birthing facilities
23under subsection (c) of this Section.
24 Section 95. No acceleration or delay. Where this Act makes
25changes in a statute that is represented in this Act by text

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1that is not yet or no longer in effect (for example, a Section
2represented by multiple versions), the use of that text does
3not accelerate or delay the taking effect of (i) the changes
4made by this Act or (ii) provisions derived from any other
5Public Act.