NEWBORN HEARING SCREENING

Illinois General Assembly - Full Text of HB4215

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB4215

Introduced 1/14/2026, by Rep. Diane Blair-Sherlock and Michelle Mussman

SYNOPSIS AS INTRODUCED:

20 ILCS 2310/2310-90

was 20 ILCS 2310/55.09
30 ILCS 500/1-10
305 ILCS 5/5-5
410 ILCS 240/Act title
410 ILCS 240/0.01

from Ch. 111 1/2, par. 4902.9
410 ILCS 240/2

from Ch. 111 1/2, par. 4904
410 ILCS 513/30

Amends the Newborn Metabolic Screening Act. Changes the short title
of the Act to the Newborn Screening Act. Specifies that, for purposes of
the Act, hearing disorders are a genetic, metabolic, or congenital anomaly
for which newborns must be screened. Provides that, beginning July 1,
2026, the base fee for newborn screening services shall be $165. Provides
that 22% of the base fee must be allocated to the Department of Public
Health for the Early Hearing Detection and Intervention Program. Provides
that other State and federal funds for expenses related to metabolic,
hearing, or congenital disorder screening, follow-up, and treatment
programs (rather than only metabolic screening, follow-up, and treatment
programs) may also be placed in the Metabolic Screening and Treatment
Fund. In provisions concerning the temporary testing of all blood and
biological specimens, excludes hearing screenings. Makes conforming and
technical changes to the title of the Act, the Department of Public Health
Powers and Duties Law of the Civil Administrative Code of Illinois, the
Illinois Procurement Code, the Illinois Public Aid Code, and the Genetic
Information Privacy Act. Effective immediately.
LRB104 15597 BDA 28764 b

A BILL FOR

HB4215
LRB104 15597 BDA 28764 b
1

AN ACT concerning health.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 5.
The Department of Public Health Powers and
5
Duties Law of the Civil Administrative Code of Illinois is
6
amended by changing Section 2310-90 as follows:

7

(20 ILCS 2310/2310-90)

(was 20 ILCS 2310/55.09)
8

Sec. 2310-90.
Laboratories; fees; Public Health Laboratory
9
Services Revolving Fund.
To maintain physical, chemical,
10
bacteriological, and biological laboratories; to make
11
examinations of milk, water, atmosphere, sewage, wastes, and
12
other substances, and equipment and processes relating
13
thereto; to make diagnostic tests for diseases and tests for
14
the evaluation of health hazards considered necessary for the
15
protection of the people of the State; and to assess a
16
reasonable fee for services provided as established by
17
regulation, under the Illinois Administrative Procedure Act,
18
which shall not exceed the Department's actual costs to
19
provide these services.
20

Excepting fees collected under the Newborn
Metabolic

21
Screening Act and the Lead Poisoning Prevention Act, all fees
22
shall be deposited into the Public Health Laboratory Services
23
Revolving Fund. Other State and federal funds related to

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LRB104 15597 BDA 28764 b
1
laboratory services may also be deposited into the Fund, and
2
all interest that accrues on the moneys in the Fund shall be
3
deposited into the Fund.
4

Moneys shall be appropriated from the Fund solely for the
5
purposes of testing specimens submitted in support of
6
Department programs established for the protection of human
7
health, welfare, and safety, and for testing specimens
8
submitted by physicians and other health care providers, to
9
determine whether chemically hazardous, biologically
10
infectious substances, or other disease causing conditions are
11
present.
12
(Source: P.A. 96-328, eff. 8-11-09.)

13

Section 10.
The Illinois Procurement Code is amended by
14
changing Section 1-10 as follows:

15

(30 ILCS 500/1-10)
16

Sec. 1-10.
Application.
17

(a) This Code applies only to procurements for which
18
bidders, offerors, potential contractors, or contractors were
19
first solicited on or after July 1, 1998. This Code shall not
20
be construed to affect or impair any contract, or any
21
provision of a contract, entered into based on a solicitation
22
prior to the implementation date of this Code as described in
23
Article 99, including, but not limited to, any covenant
24
entered into with respect to any revenue bonds or similar

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1
instruments. All procurements for which contracts are
2
solicited between the effective date of Articles 50 and 99 and
3
July 1, 1998 shall be substantially in accordance with this
4
Code and its intent.
5

(b) This Code shall apply regardless of the source of the
6
funds with which the contracts are paid, including federal
7
assistance moneys. This Code shall not apply to:
8

(1) Contracts between the State and its political
9

subdivisions or other governments, or between State
10

governmental bodies, except as specifically provided in
11

this Code.
12

(2) Grants, except for the filing requirements of
13

Section 20-80.
14

(3) Purchase of care, except as provided in Section
15

5-30.6 of the Illinois Public Aid Code and this Section.
16

(4) Hiring of an individual as an employee and not as
17

an independent contractor, whether pursuant to an
18

employment code or policy or by contract directly with
19

that individual.
20

(5) Collective bargaining contracts.
21

(6) Purchase of real estate, except that notice of
22

this type of contract with a value of more than $25,000
23

must be published in the Procurement Bulletin within 10
24

calendar days after the deed is recorded in the county of
25

jurisdiction. The notice shall identify the real estate
26

purchased, the names of all parties to the contract, the

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value of the contract, and the effective date of the
2

contract.
3

(7) Contracts necessary to prepare for anticipated
4

litigation, enforcement actions, or investigations,
5

provided that the chief legal counsel to the Governor
6

shall give his or her prior approval when the procuring
7

agency is one subject to the jurisdiction of the Governor,
8

and provided that the chief legal counsel of any other
9

procuring entity subject to this Code shall give his or
10

her prior approval when the procuring entity is not one
11

subject to the jurisdiction of the Governor.
12

(8) (Blank).
13

(9) Procurement expenditures by the Illinois
14

Conservation Foundation when only private funds are used.
15

(10) (Blank).
16

(11) Public-private agreements entered into according
17

to the procurement requirements of Section 20 of the
18

Public-Private Partnerships for Transportation Act and
19

design-build agreements entered into according to the
20

procurement requirements of Section 25 of the
21

Public-Private Partnerships for Transportation Act.
22

(12) (A) Contracts for legal, financial, and other
23

professional and artistic services entered into by the
24

Illinois Finance Authority in which the State of Illinois
25

is not obligated. Such contracts shall be awarded through
26

a competitive process authorized by the members of the

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Illinois Finance Authority and are subject to Sections
2

5-30, 20-160, 50-13, 50-20, 50-35, and 50-37 of this Code,
3

as well as the final approval by the members of the
4

Illinois Finance Authority of the terms of the contract.
5

(B) Contracts for legal and financial services entered
6

into by the Illinois Housing Development Authority in
7

connection with the issuance of bonds in which the State
8

of Illinois is not obligated. Such contracts shall be
9

awarded through a competitive process authorized by the
10

members of the Illinois Housing Development Authority and
11

are subject to Sections 5-30, 20-160, 50-13, 50-20, 50-35,
12

and 50-37 of this Code, as well as the final approval by
13

the members of the Illinois Housing Development Authority
14

of the terms of the contract.
15

(13) Contracts for services, commodities, and
16

equipment to support the delivery of timely forensic
17

science services in consultation with and subject to the
18

approval of the Chief Procurement Officer as provided in
19

subsection (d) of Section 5-4-3a of the Unified Code of
20

Corrections, except for the requirements of Sections
21

20-60, 20-65, 20-70, and 20-160 and Article 50 of this
22

Code; however, the Chief Procurement Officer may, in
23

writing with justification, waive any certification
24

required under Article 50 of this Code. For any contracts
25

for services which are currently provided by members of a
26

collective bargaining agreement, the applicable terms of

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the collective bargaining agreement concerning
2

subcontracting shall be followed.
3

On and after January 1, 2019, this paragraph (13),
4

except for this sentence, is inoperative.
5

(14) Contracts for participation expenditures required
6

by a domestic or international trade show or exhibition of
7

an exhibitor, member, or sponsor.
8

(15) Contracts with a railroad or utility that
9

requires the State to reimburse the railroad or utilities
10

for the relocation of utilities for construction or other
11

public purpose. Contracts included within this paragraph
12

(15) shall include, but not be limited to, those
13

associated with: relocations, crossings, installations,
14

and maintenance. For the purposes of this paragraph (15),
15

"railroad" means any form of non-highway ground
16

transportation that runs on rails or electromagnetic
17

guideways and "utility" means: (1) public utilities as
18

defined in Section 3-105 of the Public Utilities Act, (2)
19

telecommunications carriers as defined in Section 13-202
20

of the Public Utilities Act, (3) electric cooperatives as
21

defined in Section 3.4 of the Electric Supplier Act, (4)
22

telephone or telecommunications cooperatives as defined in
23

Section 13-212 of the Public Utilities Act, (5) rural
24

water or waste water systems with 10,000 connections or
25

less, (6) a holder as defined in Section 21-201 of the
26

Public Utilities Act, and (7) municipalities owning or

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operating utility systems consisting of public utilities
2

as that term is defined in Section 11-117-2 of the
3

Illinois Municipal Code.
4

(16) Procurement expenditures necessary for the
5

Department of Public Health to provide the delivery of
6

timely newborn screening services in accordance with the
7

Newborn
Metabolic
Screening Act.
8

(17) Procurement expenditures necessary for the
9

Department of Agriculture, the Department of Financial and
10

Professional Regulation, the Department of Human Services,
11

and the Department of Public Health to implement the
12

Compassionate Use of Medical Cannabis Program and Opioid
13

Alternative Pilot Program requirements and ensure access
14

to medical cannabis for patients with debilitating medical
15

conditions in accordance with the Compassionate Use of
16

Medical Cannabis Program Act.
17

(18) This Code does not apply to any procurements
18

necessary for the Department of Agriculture, the
19

Department of Financial and Professional Regulation, the
20

Department of Human Services, the Department of Commerce
21

and Economic Opportunity, and the Department of Public
22

Health to implement the Cannabis Regulation and Tax Act if
23

the applicable agency has made a good faith determination
24

that it is necessary and appropriate for the expenditure
25

to fall within this exemption and if the process is
26

conducted in a manner substantially in accordance with the

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LRB104 15597 BDA 28764 b
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requirements of Sections 20-160, 25-60, 30-22, 50-5,
2

50-10, 50-10.5, 50-12, 50-13, 50-15, 50-20, 50-21, 50-35,
3

50-36, 50-37, 50-38, and 50-50 of this Code; however, for
4

Section 50-35, compliance applies only to contracts or
5

subcontracts over $100,000. Notice of each contract
6

entered into under this paragraph (18) that is related to
7

the procurement of goods and services identified in
8

paragraph (1) through (9) of this subsection shall be
9

published in the Procurement Bulletin within 14 calendar
10

days after contract execution. The Chief Procurement
11

Officer shall prescribe the form and content of the
12

notice. Each agency shall provide the Chief Procurement
13

Officer, on a monthly basis, in the form and content
14

prescribed by the Chief Procurement Officer, a report of
15

contracts that are related to the procurement of goods and
16

services identified in this subsection. At a minimum, this
17

report shall include the name of the contractor, a
18

description of the supply or service provided, the total
19

amount of the contract, the term of the contract, and the
20

exception to this Code utilized. A copy of any or all of
21

these contracts shall be made available to the Chief
22

Procurement Officer immediately upon request. The Chief
23

Procurement Officer shall submit a report to the Governor
24

and General Assembly no later than November 1 of each year
25

that includes, at a minimum, an annual summary of the
26

monthly information reported to the Chief Procurement

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LRB104 15597 BDA 28764 b
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Officer. This exemption becomes inoperative 5 years after
2

June 25, 2019 (the effective date of Public Act 101-27).
3

(19) Acquisition of modifications or adjustments,
4

limited to assistive technology devices and assistive
5

technology services, adaptive equipment, repairs, and
6

replacement parts to provide reasonable accommodations (i)
7

that enable a qualified applicant with a disability to
8

complete the job application process and be considered for
9

the position such qualified applicant desires, (ii) that
10

modify or adjust the work environment to enable a
11

qualified current employee with a disability to perform
12

the essential functions of the position held by that
13

employee, (iii) to enable a qualified current employee
14

with a disability to enjoy equal benefits and privileges
15

of employment as are enjoyed by other similarly situated
16

employees without disabilities, and (iv) that allow a
17

customer, client, claimant, or member of the public
18

seeking State services full use and enjoyment of and
19

access to its programs, services, or benefits.
20

For purposes of this paragraph (19):
21

"Assistive technology devices" means any item, piece
22

of equipment, or product system, whether acquired
23

commercially off the shelf, modified, or customized, that
24

is used to increase, maintain, or improve functional
25

capabilities of individuals with disabilities.
26

"Assistive technology services" means any service that

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LRB104 15597 BDA 28764 b
1

directly assists an individual with a disability in
2

selection, acquisition, or use of an assistive technology
3

device.
4

"Qualified" has the same meaning and use as provided
5

under the federal Americans with Disabilities Act when
6

describing an individual with a disability.
7

(20) Procurement expenditures necessary for the
8

Illinois Commerce Commission to hire third-party
9

facilitators pursuant to Sections 16-105.17 and 16-108.18
10

of the Public Utilities Act or an ombudsman pursuant to
11

Section 16-107.5 of the Public Utilities Act, a
12

facilitator pursuant to Section 16-105.17 of the Public
13

Utilities Act, or a grid auditor pursuant to Section
14

16-105.10 of the Public Utilities Act.
15

(21) Procurement expenditures for the purchase,
16

renewal, and expansion of software, software licenses, or
17

software maintenance agreements that support the efforts
18

of the Illinois State Police to enforce, regulate, and
19

administer the Firearm Owners Identification Card Act, the
20

Firearm Concealed Carry Act, the Firearms Restraining
21

Order Act, the Firearm Dealer License Certification Act,
22

the Law Enforcement Agencies Data System (LEADS), the
23

Uniform Crime Reporting Act, the Criminal Identification
24

Act, the Illinois Uniform Conviction Information Act, and
25

the Gun Trafficking Information Act, or establish or
26

maintain record management systems necessary to conduct

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human trafficking investigations or gun trafficking or
2

other stolen firearm investigations. This paragraph (21)
3

applies to contracts entered into on or after January 10,
4

2023 (the effective date of Public Act 102-1116) and the
5

renewal of contracts that are in effect on January 10,
6

2023 (the effective date of Public Act 102-1116).
7

(22) Contracts for project management services and
8

system integration services required for the completion of
9

the State's enterprise resource planning project. This
10

exemption becomes inoperative 5 years after June 7, 2023
11

(the effective date of the changes made to this Section by
12

Public Act 103-8). This paragraph (22) applies to
13

contracts entered into on or after June 7, 2023 (the
14

effective date of the changes made to this Section by
15

Public Act 103-8) and the renewal of contracts that are in
16

effect on June 7, 2023 (the effective date of the changes
17

made to this Section by Public Act 103-8).
18

(23) Procurements necessary for the Department of
19

Insurance to implement the Illinois Health Benefits
20

Exchange Law if the Department of Insurance has made a
21

good faith determination that it is necessary and
22

appropriate for the expenditure to fall within this
23

exemption. The procurement process shall be conducted in a
24

manner substantially in accordance with the requirements
25

of Sections 20-160 and 25-60 and Article 50 of this Code. A
26

copy of these contracts shall be made available to the

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1

Chief Procurement Officer immediately upon request. This
2

paragraph is inoperative 5 years after June 27, 2023 (the
3

effective date of Public Act 103-103).
4

(24) Contracts for public education programming,
5

noncommercial sustaining announcements, public service
6

announcements, and public awareness and education
7

messaging with the nonprofit trade associations of the
8

providers of those services that inform the public on
9

immediate and ongoing health and safety risks and hazards.
10

(25) Procurements necessary for the Department of
11

Early Childhood to implement the Department of Early
12

Childhood Act if the Department has made a good faith
13

determination that it is necessary and appropriate for the
14

expenditure to fall within this exemption. This exemption
15

shall only be used for products and services procured
16

solely for use by the Department of Early Childhood. The
17

procurements may include those necessary to design and
18

build integrated, operational systems of programs and
19

services. The procurements may include, but are not
20

limited to, those necessary to align and update program
21

standards, integrate funding systems, design and establish
22

data and reporting systems, align and update models for
23

technical assistance and professional development, design
24

systems to manage grants and ensure compliance, design and
25

implement management and operational structures, and
26

establish new means of engaging with families, educators,

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1

providers, and stakeholders. The procurement processes
2

shall be conducted in a manner substantially in accordance
3

with the requirements of Article 50 (ethics) and Sections
4

5-5 (Procurement Policy Board), 5-7 (Commission on Equity
5

and Inclusion), 20-80 (contract files), 20-120
6

(subcontractors), 20-155 (paperwork), 20-160
7

(ethics/campaign contribution prohibitions), 25-60
8

(prevailing wage), and 25-90 (prohibited and authorized
9

cybersecurity) of this Code. Beginning January 1, 2025,
10

the Department of Early Childhood shall provide a
11

quarterly report to the General Assembly detailing a list
12

of expenditures and contracts for which the Department
13

uses this exemption. This paragraph is inoperative on and
14

after July 1, 2027.
15

(26)

(25)
Procurements that are necessary for
16

increasing the recruitment and retention of State
17

employees, particularly minority candidates for
18

employment, including:
19

(A) procurements related to registration fees for
20

job fairs and other outreach and recruitment events;
21

(B) production of recruitment materials; and
22

(C) other services related to recruitment and
23

retention of State employees.
24

The exemption under this paragraph
(26)

(25)
applies
25

only if the State agency has made a good faith
26

determination that it is necessary and appropriate for the

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1

expenditure to fall within this paragraph
(26)

(25)
. The
2

procurement process under this paragraph
(26)

(25)
shall
3

be conducted in a manner substantially in accordance with
4

the requirements of Sections 20-160 and 25-60 and Article
5

50 of this Code. A copy of these contracts shall be made
6

available to the Chief Procurement Officer immediately
7

upon request. Nothing in this paragraph
(26)

(25)

8

authorizes the replacement or diminishment of State
9

responsibilities in hiring or the positions that
10

effectuate that hiring. This paragraph
(26)

(25)
is
11

inoperative on and after June 30, 2029.
12

Notwithstanding any other provision of law, for contracts
13
with an annual value of more than $100,000 entered into on or
14
after October 1, 2017 under an exemption provided in any
15
paragraph of this subsection (b), except paragraph (1), (2),
16
or (5), each State agency shall post to the appropriate
17
procurement bulletin the name of the contractor, a description
18
of the supply or service provided, the total amount of the
19
contract, the term of the contract, and the exception to the
20
Code utilized. The chief procurement officer shall submit a
21
report to the Governor and General Assembly no later than
22
November 1 of each year that shall include, at a minimum, an
23
annual summary of the monthly information reported to the
24
chief procurement officer.
25

(c) This Code does not apply to the electric power
26
procurement process provided for under Section 1-75 of the

HB4215
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1
Illinois Power Agency Act and Section 16-111.5 of the Public
2
Utilities Act. This Code does not apply to the procurement of
3
technical and policy experts pursuant to Section 1-129 of the
4
Illinois Power Agency Act.
5

(d) Except for Section 20-160 and Article 50 of this Code,
6
and as expressly required by Section 9.1 of the Illinois
7
Lottery Law, the provisions of this Code do not apply to the
8
procurement process provided for under Section 9.1 of the
9
Illinois Lottery Law.
10

(e) This Code does not apply to the process used by the
11
Capital Development Board to retain a person or entity to
12
assist the Capital Development Board with its duties related
13
to the determination of costs of a clean coal SNG brownfield
14
facility, as defined by Section 1-10 of the Illinois Power
15
Agency Act, as required in subsection (h-3) of Section 9-220
16
of the Public Utilities Act, including calculating the range
17
of capital costs, the range of operating and maintenance
18
costs, or the sequestration costs or monitoring the
19
construction of clean coal SNG brownfield facility for the
20
full duration of construction.
21

(f) (Blank).
22

(g) (Blank).
23

(h) This Code does not apply to the process to procure or
24
contracts entered into in accordance with Sections 11-5.2 and
25
11-5.3 of the Illinois Public Aid Code.
26

(i) Each chief procurement officer may access records

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1
necessary to review whether a contract, purchase, or other
2
expenditure is or is not subject to the provisions of this
3
Code, unless such records would be subject to attorney-client
4
privilege.
5

(j) This Code does not apply to the process used by the
6
Capital Development Board to retain an artist or work or works
7
of art as required in Section 14 of the Capital Development
8
Board Act.
9

(k) This Code does not apply to the process to procure
10
contracts, or contracts entered into, by the State Board of
11
Elections or the State Electoral Board for hearing officers
12
appointed pursuant to the Election Code.
13

(l) This Code does not apply to the processes used by the
14
Illinois Student Assistance Commission to procure supplies and
15
services paid for from the private funds of the Illinois
16
Prepaid Tuition Fund. As used in this subsection (l), "private
17
funds" means funds derived from deposits paid into the
18
Illinois Prepaid Tuition Trust Fund and the earnings thereon.
19

(m) This Code shall apply regardless of the source of
20
funds with which contracts are paid, including federal
21
assistance moneys. Except as specifically provided in this
22
Code, this Code shall not apply to procurement expenditures
23
necessary for the Department of Public Health to conduct the
24
Healthy Illinois Survey in accordance with Section 2310-431 of
25
the Department of Public Health Powers and Duties Law of the
26
Civil Administrative Code of Illinois.

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1
(Source: P.A. 102-175, eff. 7-29-21; 102-483, eff 1-1-22;
2
102-558, eff. 8-20-21; 102-600, eff. 8-27-21; 102-662, eff.
3
9-15-21; 102-721, eff. 1-1-23; 102-813, eff. 5-13-22;
4
102-1116, eff. 1-10-23; 103-8, eff. 6-7-23; 103-103, eff.
5
6-27-23; 103-570, eff. 1-1-24; 103-580, eff. 12-8-23; 103-594,
6
eff. 6-25-24; 103-605, eff. 7-1-24; 103-865, eff. 1-1-25;
7
revised 11-26-24.)

8

Section 15.
The Illinois Public Aid Code is amended by
9
changing Section 5-5 as follows:

10

(305 ILCS 5/5-5)
11

(Text of Section before amendment by P.A. 103-808
)
12

Sec. 5-5.
Medical services.
The Illinois Department, by
13
rule, shall determine the quantity and quality of and the rate
14
of reimbursement for the medical assistance for which payment
15
will be authorized, and the medical services to be provided,
16
which may include all or part of the following: (1) inpatient
17
hospital services; (2) outpatient hospital services; (3) other
18
laboratory and X-ray services; (4) skilled nursing home
19
services; (5) physicians' services whether furnished in the
20
office, the patient's home, a hospital, a skilled nursing
21
home, or elsewhere; (6) medical care, or any other type of
22
remedial care furnished by licensed practitioners; (7) home
23
health care services; (8) private duty nursing service; (9)
24
clinic services; (10) dental services, including prevention

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

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discover evidence which may be used in criminal proceedings
2
arising from the sexual assault; (16) the diagnosis and
3
treatment of sickle cell anemia; (16.5) services performed by
4
a chiropractic physician licensed under the Medical Practice
5
Act of 1987 and acting within the scope of his or her license,
6
including, but not limited to, chiropractic manipulative
7
treatment; and (17) any other medical care, and any other type
8
of remedial care recognized under the laws of this State. The
9
term "any other type of remedial care" shall include nursing
10
care and nursing home service for persons who rely on
11
treatment by spiritual means alone through prayer for healing.
12

Notwithstanding any other provision of this Section, a
13
comprehensive tobacco use cessation program that includes
14
purchasing prescription drugs or prescription medical devices
15
approved by the Food and Drug Administration shall be covered
16
under the medical assistance program under this Article for
17
persons who are otherwise eligible for assistance under this
18
Article.
19

Notwithstanding any other provision of this Code,
20
reproductive health care that is otherwise legal in Illinois
21
shall be covered under the medical assistance program for
22
persons who are otherwise eligible for medical assistance
23
under this Article.
24

Notwithstanding any other provision of this Section, all
25
tobacco cessation medications approved by the United States
26
Food and Drug Administration and all individual and group

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tobacco cessation counseling services and telephone-based
2
counseling services and tobacco cessation medications provided
3
through the Illinois Tobacco Quitline shall be covered under
4
the medical assistance program for persons who are otherwise
5
eligible for assistance under this Article. The Department
6
shall comply with all federal requirements necessary to obtain
7
federal financial participation, as specified in 42 CFR
8
433.15(b)(7), for telephone-based counseling services provided
9
through the Illinois Tobacco Quitline, including, but not
10
limited to: (i) entering into a memorandum of understanding or
11
interagency agreement with the Department of Public Health, as
12
administrator of the Illinois Tobacco Quitline; and (ii)
13
developing a cost allocation plan for Medicaid-allowable
14
Illinois Tobacco Quitline services in accordance with 45 CFR
15
95.507. The Department shall submit the memorandum of
16
understanding or interagency agreement, the cost allocation
17
plan, and all other necessary documentation to the Centers for
18
Medicare and Medicaid Services for review and approval.
19
Coverage under this paragraph shall be contingent upon federal
20
approval.
21

Notwithstanding any other provision of this Code, the
22
Illinois Department may not require, as a condition of payment
23
for any laboratory test authorized under this Article, that a
24
physician's handwritten signature appear on the laboratory
25
test order form. The Illinois Department may, however, impose
26
other appropriate requirements regarding laboratory test order

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documentation.
2

Upon receipt of federal approval of an amendment to the
3
Illinois Title XIX State Plan for this purpose, the Department
4
shall authorize the Chicago Public Schools (CPS) to procure a
5
vendor or vendors to manufacture eyeglasses for individuals
6
enrolled in a school within the CPS system. CPS shall ensure
7
that its vendor or vendors are enrolled as providers in the
8
medical assistance program and in any capitated Medicaid
9
managed care entity (MCE) serving individuals enrolled in a
10
school within the CPS system. Under any contract procured
11
under this provision, the vendor or vendors must serve only
12
individuals enrolled in a school within the CPS system. Claims
13
for services provided by CPS's vendor or vendors to recipients
14
of benefits in the medical assistance program under this Code,
15
the Children's Health Insurance Program, or the Covering ALL
16
KIDS Health Insurance Program shall be submitted to the
17
Department or the MCE in which the individual is enrolled for
18
payment and shall be reimbursed at the Department's or the
19
MCE's established rates or rate methodologies for eyeglasses.
20

On and after July 1, 2012, the Department of Healthcare
21
and Family Services may provide the following services to
22
persons eligible for assistance under this Article who are
23
participating in education, training or employment programs
24
operated by the Department of Human Services as successor to
25
the Department of Public Aid:
26

(1) dental services provided by or under the

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supervision of a dentist; and
2

(2) eyeglasses prescribed by a physician skilled in
3

the diseases of the eye, or by an optometrist, whichever
4

the person may select.
5

On and after July 1, 2018, the Department of Healthcare
6
and Family Services shall provide dental services to any adult
7
who is otherwise eligible for assistance under the medical
8
assistance program. As used in this paragraph, "dental
9
services" means diagnostic, preventative, restorative, or
10
corrective procedures, including procedures and services for
11
the prevention and treatment of periodontal disease and dental
12
caries disease, provided by an individual who is licensed to
13
practice dentistry or dental surgery or who is under the
14
supervision of a dentist in the practice of his or her
15
profession.
16

On and after July 1, 2018, targeted dental services, as
17
set forth in Exhibit D of the Consent Decree entered by the
18
United States District Court for the Northern District of
19
Illinois, Eastern Division, in the matter of Memisovski v.
20
Maram, Case No. 92 C 1982, that are provided to adults under
21
the medical assistance program shall be established at no less
22
than the rates set forth in the "New Rate" column in Exhibit D
23
of the Consent Decree for targeted dental services that are
24
provided to persons under the age of 18 under the medical
25
assistance program.
26

Subject to federal approval, on and after January 1, 2025,

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the rates paid for sedation evaluation and the provision of
2
deep sedation and intravenous sedation for the purpose of
3
dental services shall be increased by 33% above the rates in
4
effect on December 31, 2024. The rates paid for nitrous oxide
5
sedation shall not be impacted by this paragraph and shall
6
remain the same as the rates in effect on December 31, 2024.
7

Notwithstanding any other provision of this Code and
8
subject to federal approval, the Department may adopt rules to
9
allow a dentist who is volunteering his or her service at no
10
cost to render dental services through an enrolled
11
not-for-profit health clinic without the dentist personally
12
enrolling as a participating provider in the medical
13
assistance program. A not-for-profit health clinic shall
14
include a public health clinic or Federally Qualified Health
15
Center or other enrolled provider, as determined by the
16
Department, through which dental services covered under this
17
Section are performed. The Department shall establish a
18
process for payment of claims for reimbursement for covered
19
dental services rendered under this provision.
20

Subject to appropriation and to federal approval, the
21
Department shall file administrative rules updating the
22
Handicapping Labio-Lingual Deviation orthodontic scoring tool
23
by January 1, 2025, or as soon as practicable.
24

On and after January 1, 2022, the Department of Healthcare
25
and Family Services shall administer and regulate a
26
school-based dental program that allows for the out-of-office

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delivery of preventative dental services in a school setting
2
to children under 19 years of age. The Department shall
3
establish, by rule, guidelines for participation by providers
4
and set requirements for follow-up referral care based on the
5
requirements established in the Dental Office Reference Manual
6
published by the Department that establishes the requirements
7
for dentists participating in the All Kids Dental School
8
Program. Every effort shall be made by the Department when
9
developing the program requirements to consider the different
10
geographic differences of both urban and rural areas of the
11
State for initial treatment and necessary follow-up care. No
12
provider shall be charged a fee by any unit of local government
13
to participate in the school-based dental program administered
14
by the Department. Nothing in this paragraph shall be
15
construed to limit or preempt a home rule unit's or school
16
district's authority to establish, change, or administer a
17
school-based dental program in addition to, or independent of,
18
the school-based dental program administered by the
19
Department.
20

The Illinois Department, by rule, may distinguish and
21
classify the medical services to be provided only in
22
accordance with the classes of persons designated in Section
23
5-2.
24

The Department of Healthcare and Family Services must
25
provide coverage and reimbursement for amino acid-based
26
elemental formulas, regardless of delivery method, for the

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diagnosis and treatment of (i) eosinophilic disorders and (ii)
2
short bowel syndrome when the prescribing physician has issued
3
a written order stating that the amino acid-based elemental
4
formula is medically necessary.
5

The Illinois Department shall authorize the provision of,
6
and shall authorize payment for, screening by low-dose
7
mammography for the presence of occult breast cancer for
8
individuals 35 years of age or older who are eligible for
9
medical assistance under this Article, as follows:
10

(A) A baseline mammogram for individuals 35 to 39
11

years of age.
12

(B) An annual mammogram for individuals 40 years of
13

age or older.
14

(C) A mammogram at the age and intervals considered
15

medically necessary by the individual's health care
16

provider for individuals under 40 years of age and having
17

a family history of breast cancer, prior personal history
18

of breast cancer, positive genetic testing, or other risk
19

factors.
20

(D) A comprehensive ultrasound screening and MRI of an
21

entire breast or breasts if a mammogram demonstrates
22

heterogeneous or dense breast tissue or when medically
23

necessary as determined by a physician licensed to
24

practice medicine in all of its branches.
25

(E) A screening MRI when medically necessary, as
26

determined by a physician licensed to practice medicine in

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all of its branches.
2

(F) A diagnostic mammogram when medically necessary,
3

as determined by a physician licensed to practice medicine
4

in all its branches, advanced practice registered nurse,
5

or physician assistant.
6

The Department shall not impose a deductible, coinsurance,
7
copayment, or any other cost-sharing requirement on the
8
coverage provided under this paragraph; except that this
9
sentence does not apply to coverage of diagnostic mammograms
10
to the extent such coverage would disqualify a high-deductible
11
health plan from eligibility for a health savings account
12
pursuant to Section 223 of the Internal Revenue Code (26
13
U.S.C. 223).
14

All screenings shall include a physical breast exam,
15
instruction on self-examination and information regarding the
16
frequency of self-examination and its value as a preventative
17
tool.
18

For purposes of this Section:
19

"Diagnostic mammogram" means a mammogram obtained using
20
diagnostic mammography.
21

"Diagnostic mammography" means a method of screening that
22
is designed to evaluate an abnormality in a breast, including
23
an abnormality seen or suspected on a screening mammogram or a
24
subjective or objective abnormality otherwise detected in the
25
breast.
26

"Low-dose mammography" means the x-ray examination of the

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breast using equipment dedicated specifically for mammography,
2
including the x-ray tube, filter, compression device, and
3
image receptor, with an average radiation exposure delivery of
4
less than one rad per breast for 2 views of an average size
5
breast. The term also includes digital mammography and
6
includes breast tomosynthesis.
7

"Breast tomosynthesis" means a radiologic procedure that
8
involves the acquisition of projection images over the
9
stationary breast to produce cross-sectional digital
10
three-dimensional images of the breast.
11

If, at any time, the Secretary of the United States
12
Department of Health and Human Services, or its successor
13
agency, promulgates rules or regulations to be published in
14
the Federal Register or publishes a comment in the Federal
15
Register or issues an opinion, guidance, or other action that
16
would require the State, pursuant to any provision of the
17
Patient Protection and Affordable Care Act (Public Law
18
111-148), including, but not limited to, 42 U.S.C.
19
18031(d)(3)(B) or any successor provision, to defray the cost
20
of any coverage for breast tomosynthesis outlined in this
21
paragraph, then the requirement that an insurer cover breast
22
tomosynthesis is inoperative other than any such coverage
23
authorized under Section 1902 of the Social Security Act, 42
24
U.S.C. 1396a, and the State shall not assume any obligation
25
for the cost of coverage for breast tomosynthesis set forth in
26
this paragraph.

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On and after January 1, 2016, the Department shall ensure
2
that all networks of care for adult clients of the Department
3
include access to at least one breast imaging Center of
4
Imaging Excellence as certified by the American College of
5
Radiology.
6

On and after January 1, 2012, providers participating in a
7
quality improvement program approved by the Department shall
8
be reimbursed for screening and diagnostic mammography at the
9
same rate as the Medicare program's rates, including the
10
increased reimbursement for digital mammography and, after
11
January 1, 2023 (the effective date of Public Act 102-1018),
12
breast tomosynthesis.
13

The Department shall convene an expert panel including
14
representatives of hospitals, free-standing mammography
15
facilities, and doctors, including radiologists, to establish
16
quality standards for mammography.
17

On and after January 1, 2017, providers participating in a
18
breast cancer treatment quality improvement program approved
19
by the Department shall be reimbursed for breast cancer
20
treatment at a rate that is no lower than 95% of the Medicare
21
program's rates for the data elements included in the breast
22
cancer treatment quality program.
23

The Department shall convene an expert panel, including
24
representatives of hospitals, free-standing breast cancer
25
treatment centers, breast cancer quality organizations, and
26
doctors, including breast surgeons, reconstructive breast

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surgeons, oncologists, and primary care providers to establish
2
quality standards for breast cancer treatment.
3

Subject to federal approval, the Department shall
4
establish a rate methodology for mammography at federally
5
qualified health centers and other encounter-rate clinics.
6
These clinics or centers may also collaborate with other
7
hospital-based mammography facilities. By January 1, 2016, the
8
Department shall report to the General Assembly on the status
9
of the provision set forth in this paragraph.
10

The Department shall establish a methodology to remind
11
individuals who are age-appropriate for screening mammography,
12
but who have not received a mammogram within the previous 18
13
months, of the importance and benefit of screening
14
mammography. The Department shall work with experts in breast
15
cancer outreach and patient navigation to optimize these
16
reminders and shall establish a methodology for evaluating
17
their effectiveness and modifying the methodology based on the
18
evaluation.
19

The Department shall establish a performance goal for
20
primary care providers with respect to their female patients
21
over age 40 receiving an annual mammogram. This performance
22
goal shall be used to provide additional reimbursement in the
23
form of a quality performance bonus to primary care providers
24
who meet that goal.
25

The Department shall devise a means of case-managing or
26
patient navigation for beneficiaries diagnosed with breast

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1
cancer. This program shall initially operate as a pilot
2
program in areas of the State with the highest incidence of
3
mortality related to breast cancer. At least one pilot program
4
site shall be in the metropolitan Chicago area and at least one
5
site shall be outside the metropolitan Chicago area. On or
6
after July 1, 2016, the pilot program shall be expanded to
7
include one site in western Illinois, one site in southern
8
Illinois, one site in central Illinois, and 4 sites within
9
metropolitan Chicago. An evaluation of the pilot program shall
10
be carried out measuring health outcomes and cost of care for
11
those served by the pilot program compared to similarly
12
situated patients who are not served by the pilot program.
13

The Department shall require all networks of care to
14
develop a means either internally or by contract with experts
15
in navigation and community outreach to navigate cancer
16
patients to comprehensive care in a timely fashion. The
17
Department shall require all networks of care to include
18
access for patients diagnosed with cancer to at least one
19
academic commission on cancer-accredited cancer program as an
20
in-network covered benefit.
21

The Department shall provide coverage and reimbursement
22
for a human papillomavirus (HPV) vaccine that is approved for
23
marketing by the federal Food and Drug Administration for all
24
persons between the ages of 9 and 45. Subject to federal
25
approval, the Department shall provide coverage and
26
reimbursement for a human papillomavirus (HPV) vaccine for

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persons of the age of 46 and above who have been diagnosed with
2
cervical dysplasia with a high risk of recurrence or
3
progression. The Department shall disallow any
4
preauthorization requirements for the administration of the
5
human papillomavirus (HPV) vaccine.
6

On or after July 1, 2022, individuals who are otherwise
7
eligible for medical assistance under this Article shall
8
receive coverage for perinatal depression screenings for the
9
12-month period beginning on the last day of their pregnancy.
10
Medical assistance coverage under this paragraph shall be
11
conditioned on the use of a screening instrument approved by
12
the Department.
13

Any medical or health care provider shall immediately
14
recommend, to any pregnant individual who is being provided
15
prenatal services and is suspected of having a substance use
16
disorder as defined in the Substance Use Disorder Act,
17
referral to a local substance use disorder treatment program
18
licensed by the Department of Human Services or to a licensed
19
hospital which provides substance abuse treatment services.
20
The Department of Healthcare and Family Services shall assure
21
coverage for the cost of treatment of the drug abuse or
22
addiction for pregnant recipients in accordance with the
23
Illinois Medicaid Program in conjunction with the Department
24
of Human Services.
25

All medical providers providing medical assistance to
26
pregnant individuals under this Code shall receive information

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from the Department on the availability of services under any
2
program providing case management services for addicted
3
individuals, including information on appropriate referrals
4
for other social services that may be needed by addicted
5
individuals in addition to treatment for addiction.
6

The Illinois Department, in cooperation with the
7
Departments of Human Services (as successor to the Department
8
of Alcoholism and Substance Abuse) and Public Health, through
9
a public awareness campaign, may provide information
10
concerning treatment for alcoholism and drug abuse and
11
addiction, prenatal health care, and other pertinent programs
12
directed at reducing the number of drug-affected infants born
13
to recipients of medical assistance.
14

Neither the Department of Healthcare and Family Services
15
nor the Department of Human Services shall sanction the
16
recipient solely on the basis of the recipient's substance
17
abuse.
18

The Illinois Department shall establish such regulations
19
governing the dispensing of health services under this Article
20
as it shall deem appropriate. The Department should seek the
21
advice of formal professional advisory committees appointed by
22
the Director of the Illinois Department for the purpose of
23
providing regular advice on policy and administrative matters,
24
information dissemination and educational activities for
25
medical and health care providers, and consistency in
26
procedures to the Illinois Department.

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The Illinois Department may develop and contract with
2
Partnerships of medical providers to arrange medical services
3
for persons eligible under Section 5-2 of this Code.
4
Implementation of this Section may be by demonstration
5
projects in certain geographic areas. The Partnership shall be
6
represented by a sponsor organization. The Department, by
7
rule, shall develop qualifications for sponsors of
8
Partnerships. Nothing in this Section shall be construed to
9
require that the sponsor organization be a medical
10
organization.
11

The sponsor must negotiate formal written contracts with
12
medical providers for physician services, inpatient and
13
outpatient hospital care, home health services, treatment for
14
alcoholism and substance abuse, and other services determined
15
necessary by the Illinois Department by rule for delivery by
16
Partnerships. Physician services must include prenatal and
17
obstetrical care. The Illinois Department shall reimburse
18
medical services delivered by Partnership providers to clients
19
in target areas according to provisions of this Article and
20
the Illinois Health Finance Reform Act, except that:
21

(1) Physicians participating in a Partnership and
22

providing certain services, which shall be determined by
23

the Illinois Department, to persons in areas covered by
24

the Partnership may receive an additional surcharge for
25

such services.
26

(2) The Department may elect to consider and negotiate

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financial incentives to encourage the development of
2

Partnerships and the efficient delivery of medical care.
3

(3) Persons receiving medical services through
4

Partnerships may receive medical and case management
5

services above the level usually offered through the
6

medical assistance program.
7

Medical providers shall be required to meet certain
8
qualifications to participate in Partnerships to ensure the
9
delivery of high quality medical services. These
10
qualifications shall be determined by rule of the Illinois
11
Department and may be higher than qualifications for
12
participation in the medical assistance program. Partnership
13
sponsors may prescribe reasonable additional qualifications
14
for participation by medical providers, only with the prior
15
written approval of the Illinois Department.
16

Nothing in this Section shall limit the free choice of
17
practitioners, hospitals, and other providers of medical
18
services by clients. In order to ensure patient freedom of
19
choice, the Illinois Department shall immediately promulgate
20
all rules and take all other necessary actions so that
21
provided services may be accessed from therapeutically
22
certified optometrists to the full extent of the Illinois
23
Optometric Practice Act of 1987 without discriminating between
24
service providers.
25

The Department shall apply for a waiver from the United
26
States Health Care Financing Administration to allow for the

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implementation of Partnerships under this Section.
2

The Illinois Department shall require health care
3
providers to maintain records that document the medical care
4
and services provided to recipients of Medical Assistance
5
under this Article. Such records must be retained for a period
6
of not less than 6 years from the date of service or as
7
provided by applicable State law, whichever period is longer,
8
except that if an audit is initiated within the required
9
retention period then the records must be retained until the
10
audit is completed and every exception is resolved. The
11
Illinois Department shall require health care providers to
12
make available, when authorized by the patient, in writing,
13
the medical records in a timely fashion to other health care
14
providers who are treating or serving persons eligible for
15
Medical Assistance under this Article. All dispensers of
16
medical services shall be required to maintain and retain
17
business and professional records sufficient to fully and
18
accurately document the nature, scope, details and receipt of
19
the health care provided to persons eligible for medical
20
assistance under this Code, in accordance with regulations
21
promulgated by the Illinois Department. The rules and
22
regulations shall require that proof of the receipt of
23
prescription drugs, dentures, prosthetic devices and
24
eyeglasses by eligible persons under this Section accompany
25
each claim for reimbursement submitted by the dispenser of
26
such medical services. No such claims for reimbursement shall

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be approved for payment by the Illinois Department without
2
such proof of receipt, unless the Illinois Department shall
3
have put into effect and shall be operating a system of
4
post-payment audit and review which shall, on a sampling
5
basis, be deemed adequate by the Illinois Department to assure
6
that such drugs, dentures, prosthetic devices and eyeglasses
7
for which payment is being made are actually being received by
8
eligible recipients. Within 90 days after September 16, 1984
9
(the effective date of Public Act 83-1439), the Illinois
10
Department shall establish a current list of acquisition costs
11
for all prosthetic devices and any other items recognized as
12
medical equipment and supplies reimbursable under this Article
13
and shall update such list on a quarterly basis, except that
14
the acquisition costs of all prescription drugs shall be
15
updated no less frequently than every 30 days as required by
16
Section 5-5.12.
17

Notwithstanding any other law to the contrary, the
18
Illinois Department shall, within 365 days after July 22, 2013
19
(the effective date of Public Act 98-104), establish
20
procedures to permit skilled care facilities licensed under
21
the Nursing Home Care Act to submit monthly billing claims for
22
reimbursement purposes. Following development of these
23
procedures, the Department shall, by July 1, 2016, test the
24
viability of the new system and implement any necessary
25
operational or structural changes to its information
26
technology platforms in order to allow for the direct

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acceptance and payment of nursing home claims.
2

Notwithstanding any other law to the contrary, the
3
Illinois Department shall, within 365 days after August 15,
4
2014 (the effective date of Public Act 98-963), establish
5
procedures to permit ID/DD facilities licensed under the ID/DD
6
Community Care Act and MC/DD facilities licensed under the
7
MC/DD Act to submit monthly billing claims for reimbursement
8
purposes. Following development of these procedures, the
9
Department shall have an additional 365 days to test the
10
viability of the new system and to ensure that any necessary
11
operational or structural changes to its information
12
technology platforms are implemented.
13

The Illinois Department shall require all dispensers of
14
medical services, other than an individual practitioner or
15
group of practitioners, desiring to participate in the Medical
16
Assistance program established under this Article to disclose
17
all financial, beneficial, ownership, equity, surety or other
18
interests in any and all firms, corporations, partnerships,
19
associations, business enterprises, joint ventures, agencies,
20
institutions or other legal entities providing any form of
21
health care services in this State under this Article.
22

The Illinois Department may require that all dispensers of
23
medical services desiring to participate in the medical
24
assistance program established under this Article disclose,
25
under such terms and conditions as the Illinois Department may
26
by rule establish, all inquiries from clients and attorneys

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regarding medical bills paid by the Illinois Department, which
2
inquiries could indicate potential existence of claims or
3
liens for the Illinois Department.
4

Enrollment of a vendor shall be subject to a provisional
5
period and shall be conditional for one year. During the
6
period of conditional enrollment, the Department may terminate
7
the vendor's eligibility to participate in, or may disenroll
8
the vendor from, the medical assistance program without cause.
9
Unless otherwise specified, such termination of eligibility or
10
disenrollment is not subject to the Department's hearing
11
process. However, a disenrolled vendor may reapply without
12
penalty.
13

The Department has the discretion to limit the conditional
14
enrollment period for vendors based upon the category of risk
15
of the vendor.
16

Prior to enrollment and during the conditional enrollment
17
period in the medical assistance program, all vendors shall be
18
subject to enhanced oversight, screening, and review based on
19
the risk of fraud, waste, and abuse that is posed by the
20
category of risk of the vendor. The Illinois Department shall
21
establish the procedures for oversight, screening, and review,
22
which may include, but need not be limited to: criminal and
23
financial background checks; fingerprinting; license,
24
certification, and authorization verifications; unscheduled or
25
unannounced site visits; database checks; prepayment audit
26
reviews; audits; payment caps; payment suspensions; and other

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screening as required by federal or State law.
2

The Department shall define or specify the following: (i)
3
by provider notice, the "category of risk of the vendor" for
4
each type of vendor, which shall take into account the level of
5
screening applicable to a particular category of vendor under
6
federal law and regulations; (ii) by rule or provider notice,
7
the maximum length of the conditional enrollment period for
8
each category of risk of the vendor; and (iii) by rule, the
9
hearing rights, if any, afforded to a vendor in each category
10
of risk of the vendor that is terminated or disenrolled during
11
the conditional enrollment period.
12

To be eligible for payment consideration, a vendor's
13
payment claim or bill, either as an initial claim or as a
14
resubmitted claim following prior rejection, must be received
15
by the Illinois Department, or its fiscal intermediary, no
16
later than 180 days after the latest date on the claim on which
17
medical goods or services were provided, with the following
18
exceptions:
19

(1) In the case of a provider whose enrollment is in
20

process by the Illinois Department, the 180-day period
21

shall not begin until the date on the written notice from
22

the Illinois Department that the provider enrollment is
23

complete.
24

(2) In the case of errors attributable to the Illinois
25

Department or any of its claims processing intermediaries
26

which result in an inability to receive, process, or

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adjudicate a claim, the 180-day period shall not begin
2

until the provider has been notified of the error.
3

(3) In the case of a provider for whom the Illinois
4

Department initiates the monthly billing process.
5

(4) In the case of a provider operated by a unit of
6

local government with a population exceeding 3,000,000
7

when local government funds finance federal participation
8

for claims payments.
9

For claims for services rendered during a period for which
10
a recipient received retroactive eligibility, claims must be
11
filed within 180 days after the Department determines the
12
applicant is eligible. For claims for which the Illinois
13
Department is not the primary payer, claims must be submitted
14
to the Illinois Department within 180 days after the final
15
adjudication by the primary payer.
16

In the case of long term care facilities, within 120
17
calendar days of receipt by the facility of required
18
prescreening information, new admissions with associated
19
admission documents shall be submitted through the Medical
20
Electronic Data Interchange (MEDI) or the Recipient
21
Eligibility Verification (REV) System or shall be submitted
22
directly to the Department of Human Services using required
23
admission forms. Effective September 1, 2014, admission
24
documents, including all prescreening information, must be
25
submitted through MEDI or REV. Confirmation numbers assigned
26
to an accepted transaction shall be retained by a facility to

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verify timely submittal. Once an admission transaction has
2
been completed, all resubmitted claims following prior
3
rejection are subject to receipt no later than 180 days after
4
the admission transaction has been completed.
5

Claims that are not submitted and received in compliance
6
with the foregoing requirements shall not be eligible for
7
payment under the medical assistance program, and the State
8
shall have no liability for payment of those claims.
9

To the extent consistent with applicable information and
10
privacy, security, and disclosure laws, State and federal
11
agencies and departments shall provide the Illinois Department
12
access to confidential and other information and data
13
necessary to perform eligibility and payment verifications and
14
other Illinois Department functions. This includes, but is not
15
limited to: information pertaining to licensure;
16
certification; earnings; immigration status; citizenship; wage
17
reporting; unearned and earned income; pension income;
18
employment; supplemental security income; social security
19
numbers; National Provider Identifier (NPI) numbers; the
20
National Practitioner Data Bank (NPDB); program and agency
21
exclusions; taxpayer identification numbers; tax delinquency;
22
corporate information; and death records.
23

The Illinois Department shall enter into agreements with
24
State agencies and departments, and is authorized to enter
25
into agreements with federal agencies and departments, under
26
which such agencies and departments shall share data necessary

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for medical assistance program integrity functions and
2
oversight. The Illinois Department shall develop, in
3
cooperation with other State departments and agencies, and in
4
compliance with applicable federal laws and regulations,
5
appropriate and effective methods to share such data. At a
6
minimum, and to the extent necessary to provide data sharing,
7
the Illinois Department shall enter into agreements with State
8
agencies and departments, and is authorized to enter into
9
agreements with federal agencies and departments, including,
10
but not limited to: the Secretary of State; the Department of
11
Revenue; the Department of Public Health; the Department of
12
Human Services; and the Department of Financial and
13
Professional Regulation.
14

Beginning in fiscal year 2013, the Illinois Department
15
shall set forth a request for information to identify the
16
benefits of a pre-payment, post-adjudication, and post-edit
17
claims system with the goals of streamlining claims processing
18
and provider reimbursement, reducing the number of pending or
19
rejected claims, and helping to ensure a more transparent
20
adjudication process through the utilization of: (i) provider
21
data verification and provider screening technology; and (ii)
22
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
23
post-adjudicated predictive modeling with an integrated case
24
management system with link analysis. Such a request for
25
information shall not be considered as a request for proposal
26
or as an obligation on the part of the Illinois Department to

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take any action or acquire any products or services.
2

The Illinois Department shall establish policies,
3
procedures, standards and criteria by rule for the
4
acquisition, repair and replacement of orthotic and prosthetic
5
devices and durable medical equipment. Such rules shall
6
provide, but not be limited to, the following services: (1)
7
immediate repair or replacement of such devices by recipients;
8
and (2) rental, lease, purchase or lease-purchase of durable
9
medical equipment in a cost-effective manner, taking into
10
consideration the recipient's medical prognosis, the extent of
11
the recipient's needs, and the requirements and costs for
12
maintaining such equipment. Subject to prior approval, such
13
rules shall enable a recipient to temporarily acquire and use
14
alternative or substitute devices or equipment pending repairs
15
or replacements of any device or equipment previously
16
authorized for such recipient by the Department.
17
Notwithstanding any provision of Section 5-5f to the contrary,
18
the Department may, by rule, exempt certain replacement
19
wheelchair parts from prior approval and, for wheelchairs,
20
wheelchair parts, wheelchair accessories, and related seating
21
and positioning items, determine the wholesale price by
22
methods other than actual acquisition costs.
23

The Department shall require, by rule, all providers of
24
durable medical equipment to be accredited by an accreditation
25
organization approved by the federal Centers for Medicare and
26
Medicaid Services and recognized by the Department in order to

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bill the Department for providing durable medical equipment to
2
recipients. No later than 15 months after the effective date
3
of the rule adopted pursuant to this paragraph, all providers
4
must meet the accreditation requirement.
5

In order to promote environmental responsibility, meet the
6
needs of recipients and enrollees, and achieve significant
7
cost savings, the Department, or a managed care organization
8
under contract with the Department, may provide recipients or
9
managed care enrollees who have a prescription or Certificate
10
of Medical Necessity access to refurbished durable medical
11
equipment under this Section (excluding prosthetic and
12
orthotic devices as defined in the Orthotics, Prosthetics, and
13
Pedorthics Practice Act and complex rehabilitation technology
14
products and associated services) through the State's
15
assistive technology program's reutilization program, using
16
staff with the Assistive Technology Professional (ATP)
17
Certification if the refurbished durable medical equipment:
18
(i) is available; (ii) is less expensive, including shipping
19
costs, than new durable medical equipment of the same type;
20
(iii) is able to withstand at least 3 years of use; (iv) is
21
cleaned, disinfected, sterilized, and safe in accordance with
22
federal Food and Drug Administration regulations and guidance
23
governing the reprocessing of medical devices in health care
24
settings; and (v) equally meets the needs of the recipient or
25
enrollee. The reutilization program shall confirm that the
26
recipient or enrollee is not already in receipt of the same or

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similar equipment from another service provider, and that the
2
refurbished durable medical equipment equally meets the needs
3
of the recipient or enrollee. Nothing in this paragraph shall
4
be construed to limit recipient or enrollee choice to obtain
5
new durable medical equipment or place any additional prior
6
authorization conditions on enrollees of managed care
7
organizations.
8

The Department shall execute, relative to the nursing home
9
prescreening project, written inter-agency agreements with the
10
Department of Human Services and the Department on Aging, to
11
effect the following: (i) intake procedures and common
12
eligibility criteria for those persons who are receiving
13
non-institutional services; and (ii) the establishment and
14
development of non-institutional services in areas of the
15
State where they are not currently available or are
16
undeveloped; and (iii) notwithstanding any other provision of
17
law, subject to federal approval, on and after July 1, 2012, an
18
increase in the determination of need (DON) scores from 29 to
19
37 for applicants for institutional and home and
20
community-based long term care; if and only if federal
21
approval is not granted, the Department may, in conjunction
22
with other affected agencies, implement utilization controls
23
or changes in benefit packages to effectuate a similar savings
24
amount for this population; and (iv) no later than July 1,
25
2013, minimum level of care eligibility criteria for
26
institutional and home and community-based long term care; and

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(v) no later than October 1, 2013, establish procedures to
2
permit long term care providers access to eligibility scores
3
for individuals with an admission date who are seeking or
4
receiving services from the long term care provider. In order
5
to select the minimum level of care eligibility criteria, the
6
Governor shall establish a workgroup that includes affected
7
agency representatives and stakeholders representing the
8
institutional and home and community-based long term care
9
interests. This Section shall not restrict the Department from
10
implementing lower level of care eligibility criteria for
11
community-based services in circumstances where federal
12
approval has been granted.
13

The Illinois Department shall develop and operate, in
14
cooperation with other State Departments and agencies and in
15
compliance with applicable federal laws and regulations,
16
appropriate and effective systems of health care evaluation
17
and programs for monitoring of utilization of health care
18
services and facilities, as it affects persons eligible for
19
medical assistance under this Code.
20

The Illinois Department shall report annually to the
21
General Assembly, no later than the second Friday in April of
22
1979 and each year thereafter, in regard to:
23

(a) actual statistics and trends in utilization of
24

medical services by public aid recipients;
25

(b) actual statistics and trends in the provision of
26

the various medical services by medical vendors;

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(c) current rate structures and proposed changes in
2

those rate structures for the various medical vendors; and
3

(d) efforts at utilization review and control by the
4

Illinois Department.
5

The period covered by each report shall be the 3 years
6
ending on the June 30 prior to the report. The report shall
7
include suggested legislation for consideration by the General
8
Assembly. The requirement for reporting to the General
9
Assembly shall be satisfied by filing copies of the report as
10
required by Section 3.1 of the General Assembly Organization
11
Act, and filing such additional copies with the State
12
Government Report Distribution Center for the General Assembly
13
as is required under paragraph (t) of Section 7 of the State
14
Library Act.
15

Rulemaking authority to implement Public Act 95-1045, if
16
any, is conditioned on the rules being adopted in accordance
17
with all provisions of the Illinois Administrative Procedure
18
Act and all rules and procedures of the Joint Committee on
19
Administrative Rules; any purported rule not so adopted, for
20
whatever reason, is unauthorized.
21

On and after July 1, 2012, the Department shall reduce any
22
rate of reimbursement for services or other payments or alter
23
any methodologies authorized by this Code to reduce any rate
24
of reimbursement for services or other payments in accordance
25
with Section 5-5e.
26

Because kidney transplantation can be an appropriate,

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cost-effective alternative to renal dialysis when medically
2
necessary and notwithstanding the provisions of Section 1-11
3
of this Code, beginning October 1, 2014, the Department shall
4
cover kidney transplantation for noncitizens with end-stage
5
renal disease who are not eligible for comprehensive medical
6
benefits, who meet the residency requirements of Section 5-3
7
of this Code, and who would otherwise meet the financial
8
requirements of the appropriate class of eligible persons
9
under Section 5-2 of this Code. To qualify for coverage of
10
kidney transplantation, such person must be receiving
11
emergency renal dialysis services covered by the Department.
12
Providers under this Section shall be prior approved and
13
certified by the Department to perform kidney transplantation
14
and the services under this Section shall be limited to
15
services associated with kidney transplantation.
16

Notwithstanding any other provision of this Code to the
17
contrary, on or after July 1, 2015, all
FDA-approved

FDA
18
approved
forms of medication assisted treatment prescribed for
19
the treatment of alcohol dependence or treatment of opioid
20
dependence shall be covered under both fee-for-service and
21
managed care medical assistance programs for persons who are
22
otherwise eligible for medical assistance under this Article
23
and shall not be subject to any (1) utilization control, other
24
than those established under the American Society of Addiction
25
Medicine patient placement criteria, (2) prior authorization
26
mandate, (3) lifetime restriction limit mandate, or (4)

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limitations on dosage.
2

On or after July 1, 2015, opioid antagonists prescribed
3
for the treatment of an opioid overdose, including the
4
medication product, administration devices, and any pharmacy
5
fees or hospital fees related to the dispensing, distribution,
6
and administration of the opioid antagonist, shall be covered
7
under the medical assistance program for persons who are
8
otherwise eligible for medical assistance under this Article.
9
As used in this Section, "opioid antagonist" means a drug that
10
binds to opioid receptors and blocks or inhibits the effect of
11
opioids acting on those receptors, including, but not limited
12
to, naloxone hydrochloride or any other similarly acting drug
13
approved by the U.S. Food and Drug Administration. The
14
Department shall not impose a copayment on the coverage
15
provided for naloxone hydrochloride under the medical
16
assistance program.
17

Upon federal approval, the Department shall provide
18
coverage and reimbursement for all drugs that are approved for
19
marketing by the federal Food and Drug Administration and that
20
are recommended by the federal Public Health Service or the
21
United States Centers for Disease Control and Prevention for
22
pre-exposure prophylaxis and related pre-exposure prophylaxis
23
services, including, but not limited to, HIV and sexually
24
transmitted infection screening, treatment for sexually
25
transmitted infections, medical monitoring, assorted labs, and
26
counseling to reduce the likelihood of HIV infection among

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individuals who are not infected with HIV but who are at high
2
risk of HIV infection.
3

A federally qualified health center, as defined in Section
4
1905(l)(2)(B) of the federal Social Security Act, shall be
5
reimbursed by the Department in accordance with the federally
6
qualified health center's encounter rate for services provided
7
to medical assistance recipients that are performed by a
8
dental hygienist, as defined under the Illinois Dental
9
Practice Act, working under the general supervision of a
10
dentist and employed by a federally qualified health center.
11

Within 90 days after October 8, 2021 (the effective date
12
of Public Act 102-665), the Department shall seek federal
13
approval of a State Plan amendment to expand coverage for
14
family planning services that includes presumptive eligibility
15
to individuals whose income is at or below 208% of the federal
16
poverty level. Coverage under this Section shall be effective
17
beginning no later than December 1, 2022.
18

Subject to approval by the federal Centers for Medicare
19
and Medicaid Services of a Title XIX State Plan amendment
20
electing the Program of All-Inclusive Care for the Elderly
21
(PACE) as a State Medicaid option, as provided for by Subtitle
22
I (commencing with Section 4801) of Title IV of the Balanced
23
Budget Act of 1997 (Public Law 105-33) and Part 460
24
(commencing with Section 460.2) of Subchapter E of Title 42 of
25
the Code of Federal Regulations, PACE program services shall
26
become a covered benefit of the medical assistance program,

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subject to criteria established in accordance with all
2
applicable laws.
3

Notwithstanding any other provision of this Code,
4
community-based pediatric palliative care from a trained
5
interdisciplinary team shall be covered under the medical
6
assistance program as provided in Section 15 of the Pediatric
7
Palliative Care Act.
8

Notwithstanding any other provision of this Code, within
9
12 months after June 2, 2022 (the effective date of Public Act
10
102-1037) and subject to federal approval, acupuncture
11
services performed by an acupuncturist licensed under the
12
Acupuncture Practice Act who is acting within the scope of his
13
or her license shall be covered under the medical assistance
14
program. The Department shall apply for any federal waiver or
15
State Plan amendment, if required, to implement this
16
paragraph. The Department may adopt any rules, including
17
standards and criteria, necessary to implement this paragraph.
18

Notwithstanding any other provision of this Code, the
19
medical assistance program shall, subject to federal approval,
20
reimburse hospitals for costs associated with a newborn
21
screening test for the presence of metachromatic
22
leukodystrophy, as required under the Newborn
Metabolic

23
Screening Act, at a rate not less than the fee charged by the
24
Department of Public Health. Notwithstanding any other
25
provision of this Code, the medical assistance program shall,
26
subject to appropriation and federal approval, also reimburse

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1
hospitals for costs associated with all newborn screening
2
tests added on and after
August 9, 2024 (
the effective date of
3
Public Act 103-909)

this amendatory Act of the 103rd General
4
Assembly
to the Newborn
Metabolic
Screening Act and required
5
to be performed under that Act at a rate not less than the fee
6
charged by the Department of Public Health. The Department
7
shall seek federal approval before the implementation of the
8
newborn screening test fees by the Department of Public
9
Health.
10

Notwithstanding any other provision of this Code,
11
beginning on January 1, 2024, subject to federal approval,
12
cognitive assessment and care planning services provided to a
13
person who experiences signs or symptoms of cognitive
14
impairment, as defined by the Diagnostic and Statistical
15
Manual of Mental Disorders, Fifth Edition, shall be covered
16
under the medical assistance program for persons who are
17
otherwise eligible for medical assistance under this Article.
18

Notwithstanding any other provision of this Code,
19
medically necessary reconstructive services that are intended
20
to restore physical appearance shall be covered under the
21
medical assistance program for persons who are otherwise
22
eligible for medical assistance under this Article. As used in
23
this paragraph, "reconstructive services" means treatments
24
performed on structures of the body damaged by trauma to
25
restore physical appearance.
26
(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;

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1
102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
2
55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
3
eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
4
102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5
5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
6
102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
7
1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
8
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
9
1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
10
Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
11
103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; revised
12
10-10-24.)

13

(Text of Section after amendment by P.A. 103-808
)
14

Sec. 5-5.
Medical services.
The Illinois Department, by
15
rule, shall determine the quantity and quality of and the rate
16
of reimbursement for the medical assistance for which payment
17
will be authorized, and the medical services to be provided,
18
which may include all or part of the following: (1) inpatient
19
hospital services; (2) outpatient hospital services; (3) other
20
laboratory and X-ray services; (4) skilled nursing home
21
services; (5) physicians' services whether furnished in the
22
office, the patient's home, a hospital, a skilled nursing
23
home, or elsewhere; (6) medical care, or any other type of
24
remedial care furnished by licensed practitioners; (7) home
25
health care services; (8) private duty nursing service; (9)

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

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sexual assault, including examinations and laboratory tests to
2
discover evidence which may be used in criminal proceedings
3
arising from the sexual assault; (16) the diagnosis and
4
treatment of sickle cell anemia; (16.5) services performed by
5
a chiropractic physician licensed under the Medical Practice
6
Act of 1987 and acting within the scope of his or her license,
7
including, but not limited to, chiropractic manipulative
8
treatment; and (17) any other medical care, and any other type
9
of remedial care recognized under the laws of this State. The
10
term "any other type of remedial care" shall include nursing
11
care and nursing home service for persons who rely on
12
treatment by spiritual means alone through prayer for healing.
13

Notwithstanding any other provision of this Section, a
14
comprehensive tobacco use cessation program that includes
15
purchasing prescription drugs or prescription medical devices
16
approved by the Food and Drug Administration shall be covered
17
under the medical assistance program under this Article for
18
persons who are otherwise eligible for assistance under this
19
Article.
20

Notwithstanding any other provision of this Code,
21
reproductive health care that is otherwise legal in Illinois
22
shall be covered under the medical assistance program for
23
persons who are otherwise eligible for medical assistance
24
under this Article.
25

Notwithstanding any other provision of this Section, all
26
tobacco cessation medications approved by the United States

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Food and Drug Administration and all individual and group
2
tobacco cessation counseling services and telephone-based
3
counseling services and tobacco cessation medications provided
4
through the Illinois Tobacco Quitline shall be covered under
5
the medical assistance program for persons who are otherwise
6
eligible for assistance under this Article. The Department
7
shall comply with all federal requirements necessary to obtain
8
federal financial participation, as specified in 42 CFR
9
433.15(b)(7), for telephone-based counseling services provided
10
through the Illinois Tobacco Quitline, including, but not
11
limited to: (i) entering into a memorandum of understanding or
12
interagency agreement with the Department of Public Health, as
13
administrator of the Illinois Tobacco Quitline; and (ii)
14
developing a cost allocation plan for Medicaid-allowable
15
Illinois Tobacco Quitline services in accordance with 45 CFR
16
95.507. The Department shall submit the memorandum of
17
understanding or interagency agreement, the cost allocation
18
plan, and all other necessary documentation to the Centers for
19
Medicare and Medicaid Services for review and approval.
20
Coverage under this paragraph shall be contingent upon federal
21
approval.
22

Notwithstanding any other provision of this Code, the
23
Illinois Department may not require, as a condition of payment
24
for any laboratory test authorized under this Article, that a
25
physician's handwritten signature appear on the laboratory
26
test order form. The Illinois Department may, however, impose

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other appropriate requirements regarding laboratory test order
2
documentation.
3

Upon receipt of federal approval of an amendment to the
4
Illinois Title XIX State Plan for this purpose, the Department
5
shall authorize the Chicago Public Schools (CPS) to procure a
6
vendor or vendors to manufacture eyeglasses for individuals
7
enrolled in a school within the CPS system. CPS shall ensure
8
that its vendor or vendors are enrolled as providers in the
9
medical assistance program and in any capitated Medicaid
10
managed care entity (MCE) serving individuals enrolled in a
11
school within the CPS system. Under any contract procured
12
under this provision, the vendor or vendors must serve only
13
individuals enrolled in a school within the CPS system. Claims
14
for services provided by CPS's vendor or vendors to recipients
15
of benefits in the medical assistance program under this Code,
16
the Children's Health Insurance Program, or the Covering ALL
17
KIDS Health Insurance Program shall be submitted to the
18
Department or the MCE in which the individual is enrolled for
19
payment and shall be reimbursed at the Department's or the
20
MCE's established rates or rate methodologies for eyeglasses.
21

On and after July 1, 2012, the Department of Healthcare
22
and Family Services may provide the following services to
23
persons eligible for assistance under this Article who are
24
participating in education, training or employment programs
25
operated by the Department of Human Services as successor to
26
the Department of Public Aid:

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(1) dental services provided by or under the
2

supervision of a dentist; and
3

(2) eyeglasses prescribed by a physician skilled in
4

the diseases of the eye, or by an optometrist, whichever
5

the person may select.
6

On and after July 1, 2018, the Department of Healthcare
7
and Family Services shall provide dental services to any adult
8
who is otherwise eligible for assistance under the medical
9
assistance program. As used in this paragraph, "dental
10
services" means diagnostic, preventative, restorative, or
11
corrective procedures, including procedures and services for
12
the prevention and treatment of periodontal disease and dental
13
caries disease, provided by an individual who is licensed to
14
practice dentistry or dental surgery or who is under the
15
supervision of a dentist in the practice of his or her
16
profession.
17

On and after July 1, 2018, targeted dental services, as
18
set forth in Exhibit D of the Consent Decree entered by the
19
United States District Court for the Northern District of
20
Illinois, Eastern Division, in the matter of Memisovski v.
21
Maram, Case No. 92 C 1982, that are provided to adults under
22
the medical assistance program shall be established at no less
23
than the rates set forth in the "New Rate" column in Exhibit D
24
of the Consent Decree for targeted dental services that are
25
provided to persons under the age of 18 under the medical
26
assistance program.

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Subject to federal approval, on and after January 1, 2025,
2
the rates paid for sedation evaluation and the provision of
3
deep sedation and intravenous sedation for the purpose of
4
dental services shall be increased by 33% above the rates in
5
effect on December 31, 2024. The rates paid for nitrous oxide
6
sedation shall not be impacted by this paragraph and shall
7
remain the same as the rates in effect on December 31, 2024.
8

Notwithstanding any other provision of this Code and
9
subject to federal approval, the Department may adopt rules to
10
allow a dentist who is volunteering his or her service at no
11
cost to render dental services through an enrolled
12
not-for-profit health clinic without the dentist personally
13
enrolling as a participating provider in the medical
14
assistance program. A not-for-profit health clinic shall
15
include a public health clinic or Federally Qualified Health
16
Center or other enrolled provider, as determined by the
17
Department, through which dental services covered under this
18
Section are performed. The Department shall establish a
19
process for payment of claims for reimbursement for covered
20
dental services rendered under this provision.
21

Subject to appropriation and to federal approval, the
22
Department shall file administrative rules updating the
23
Handicapping Labio-Lingual Deviation orthodontic scoring tool
24
by January 1, 2025, or as soon as practicable.
25

On and after January 1, 2022, the Department of Healthcare
26
and Family Services shall administer and regulate a

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school-based dental program that allows for the out-of-office
2
delivery of preventative dental services in a school setting
3
to children under 19 years of age. The Department shall
4
establish, by rule, guidelines for participation by providers
5
and set requirements for follow-up referral care based on the
6
requirements established in the Dental Office Reference Manual
7
published by the Department that establishes the requirements
8
for dentists participating in the All Kids Dental School
9
Program. Every effort shall be made by the Department when
10
developing the program requirements to consider the different
11
geographic differences of both urban and rural areas of the
12
State for initial treatment and necessary follow-up care. No
13
provider shall be charged a fee by any unit of local government
14
to participate in the school-based dental program administered
15
by the Department. Nothing in this paragraph shall be
16
construed to limit or preempt a home rule unit's or school
17
district's authority to establish, change, or administer a
18
school-based dental program in addition to, or independent of,
19
the school-based dental program administered by the
20
Department.
21

The Illinois Department, by rule, may distinguish and
22
classify the medical services to be provided only in
23
accordance with the classes of persons designated in Section
24
5-2.
25

The Department of Healthcare and Family Services must
26
provide coverage and reimbursement for amino acid-based

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elemental formulas, regardless of delivery method, for the
2
diagnosis and treatment of (i) eosinophilic disorders and (ii)
3
short bowel syndrome when the prescribing physician has issued
4
a written order stating that the amino acid-based elemental
5
formula is medically necessary.
6

The Illinois Department shall authorize the provision of,
7
and shall authorize payment for, screening by low-dose
8
mammography for the presence of occult breast cancer for
9
individuals 35 years of age or older who are eligible for
10
medical assistance under this Article, as follows:
11

(A) A baseline mammogram for individuals 35 to 39
12

years of age.
13

(B) An annual mammogram for individuals 40 years of
14

age or older.
15

(C) A mammogram at the age and intervals considered
16

medically necessary by the individual's health care
17

provider for individuals under 40 years of age and having
18

a family history of breast cancer, prior personal history
19

of breast cancer, positive genetic testing, or other risk
20

factors.
21

(D) A comprehensive ultrasound screening and MRI of an
22

entire breast or breasts if a mammogram demonstrates
23

heterogeneous or dense breast tissue or when medically
24

necessary as determined by a physician licensed to
25

practice medicine in all of its branches.
26

(E) A screening MRI when medically necessary, as

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determined by a physician licensed to practice medicine in
2

all of its branches.
3

(F) A diagnostic mammogram when medically necessary,
4

as determined by a physician licensed to practice medicine
5

in all its branches, advanced practice registered nurse,
6

or physician assistant.
7

(G) Molecular breast imaging (MBI) and MRI of an
8

entire breast or breasts if a mammogram demonstrates
9

heterogeneous or dense breast tissue or when medically
10

necessary as determined by a physician licensed to
11

practice medicine in all of its branches, advanced
12

practice registered nurse, or physician assistant.
13

The Department shall not impose a deductible, coinsurance,
14
copayment, or any other cost-sharing requirement on the
15
coverage provided under this paragraph; except that this
16
sentence does not apply to coverage of diagnostic mammograms
17
to the extent such coverage would disqualify a high-deductible
18
health plan from eligibility for a health savings account
19
pursuant to Section 223 of the Internal Revenue Code (26
20
U.S.C. 223).
21

All screenings shall include a physical breast exam,
22
instruction on self-examination and information regarding the
23
frequency of self-examination and its value as a preventative
24
tool.
25

For purposes of this Section:
26

"Diagnostic mammogram" means a mammogram obtained using

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diagnostic mammography.
2

"Diagnostic mammography" means a method of screening that
3
is designed to evaluate an abnormality in a breast, including
4
an abnormality seen or suspected on a screening mammogram or a
5
subjective or objective abnormality otherwise detected in the
6
breast.
7

"Low-dose mammography" means the x-ray examination of the
8
breast using equipment dedicated specifically for mammography,
9
including the x-ray tube, filter, compression device, and
10
image receptor, with an average radiation exposure delivery of
11
less than one rad per breast for 2 views of an average size
12
breast. The term also includes digital mammography and
13
includes breast tomosynthesis.
14

"Breast tomosynthesis" means a radiologic procedure that
15
involves the acquisition of projection images over the
16
stationary breast to produce cross-sectional digital
17
three-dimensional images of the breast.
18

If, at any time, the Secretary of the United States
19
Department of Health and Human Services, or its successor
20
agency, promulgates rules or regulations to be published in
21
the Federal Register or publishes a comment in the Federal
22
Register or issues an opinion, guidance, or other action that
23
would require the State, pursuant to any provision of the
24
Patient Protection and Affordable Care Act (Public Law
25
111-148), including, but not limited to, 42 U.S.C.
26
18031(d)(3)(B) or any successor provision, to defray the cost

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of any coverage for breast tomosynthesis outlined in this
2
paragraph, then the requirement that an insurer cover breast
3
tomosynthesis is inoperative other than any such coverage
4
authorized under Section 1902 of the Social Security Act, 42
5
U.S.C. 1396a, and the State shall not assume any obligation
6
for the cost of coverage for breast tomosynthesis set forth in
7
this paragraph.
8

On and after January 1, 2016, the Department shall ensure
9
that all networks of care for adult clients of the Department
10
include access to at least one breast imaging Center of
11
Imaging Excellence as certified by the American College of
12
Radiology.
13

On and after January 1, 2012, providers participating in a
14
quality improvement program approved by the Department shall
15
be reimbursed for screening and diagnostic mammography at the
16
same rate as the Medicare program's rates, including the
17
increased reimbursement for digital mammography and, after
18
January 1, 2023 (the effective date of Public Act 102-1018),
19
breast tomosynthesis.
20

The Department shall convene an expert panel including
21
representatives of hospitals, free-standing mammography
22
facilities, and doctors, including radiologists, to establish
23
quality standards for mammography.
24

On and after January 1, 2017, providers participating in a
25
breast cancer treatment quality improvement program approved
26
by the Department shall be reimbursed for breast cancer

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treatment at a rate that is no lower than 95% of the Medicare
2
program's rates for the data elements included in the breast
3
cancer treatment quality program.
4

The Department shall convene an expert panel, including
5
representatives of hospitals, free-standing breast cancer
6
treatment centers, breast cancer quality organizations, and
7
doctors, including radiologists that are trained in all forms
8
of
FDA-approved

FDA approved
breast imaging technologies,
9
breast surgeons, reconstructive breast surgeons, oncologists,
10
and primary care providers to establish quality standards for
11
breast cancer treatment.
12

Subject to federal approval, the Department shall
13
establish a rate methodology for mammography at federally
14
qualified health centers and other encounter-rate clinics.
15
These clinics or centers may also collaborate with other
16
hospital-based mammography facilities. By January 1, 2016, the
17
Department shall report to the General Assembly on the status
18
of the provision set forth in this paragraph.
19

The Department shall establish a methodology to remind
20
individuals who are age-appropriate for screening mammography,
21
but who have not received a mammogram within the previous 18
22
months, of the importance and benefit of screening
23
mammography. The Department shall work with experts in breast
24
cancer outreach and patient navigation to optimize these
25
reminders and shall establish a methodology for evaluating
26
their effectiveness and modifying the methodology based on the

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evaluation.
2

The Department shall establish a performance goal for
3
primary care providers with respect to their female patients
4
over age 40 receiving an annual mammogram. This performance
5
goal shall be used to provide additional reimbursement in the
6
form of a quality performance bonus to primary care providers
7
who meet that goal.
8

The Department shall devise a means of case-managing or
9
patient navigation for beneficiaries diagnosed with breast
10
cancer. This program shall initially operate as a pilot
11
program in areas of the State with the highest incidence of
12
mortality related to breast cancer. At least one pilot program
13
site shall be in the metropolitan Chicago area and at least one
14
site shall be outside the metropolitan Chicago area. On or
15
after July 1, 2016, the pilot program shall be expanded to
16
include one site in western Illinois, one site in southern
17
Illinois, one site in central Illinois, and 4 sites within
18
metropolitan Chicago. An evaluation of the pilot program shall
19
be carried out measuring health outcomes and cost of care for
20
those served by the pilot program compared to similarly
21
situated patients who are not served by the pilot program.
22

The Department shall require all networks of care to
23
develop a means either internally or by contract with experts
24
in navigation and community outreach to navigate cancer
25
patients to comprehensive care in a timely fashion. The
26
Department shall require all networks of care to include

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access for patients diagnosed with cancer to at least one
2
academic commission on cancer-accredited cancer program as an
3
in-network covered benefit.
4

The Department shall provide coverage and reimbursement
5
for a human papillomavirus (HPV) vaccine that is approved for
6
marketing by the federal Food and Drug Administration for all
7
persons between the ages of 9 and 45. Subject to federal
8
approval, the Department shall provide coverage and
9
reimbursement for a human papillomavirus (HPV) vaccine for
10
persons of the age of 46 and above who have been diagnosed with
11
cervical dysplasia with a high risk of recurrence or
12
progression. The Department shall disallow any
13
preauthorization requirements for the administration of the
14
human papillomavirus (HPV) vaccine.
15

On or after July 1, 2022, individuals who are otherwise
16
eligible for medical assistance under this Article shall
17
receive coverage for perinatal depression screenings for the
18
12-month period beginning on the last day of their pregnancy.
19
Medical assistance coverage under this paragraph shall be
20
conditioned on the use of a screening instrument approved by
21
the Department.
22

Any medical or health care provider shall immediately
23
recommend, to any pregnant individual who is being provided
24
prenatal services and is suspected of having a substance use
25
disorder as defined in the Substance Use Disorder Act,
26
referral to a local substance use disorder treatment program

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licensed by the Department of Human Services or to a licensed
2
hospital which provides substance abuse treatment services.
3
The Department of Healthcare and Family Services shall assure
4
coverage for the cost of treatment of the drug abuse or
5
addiction for pregnant recipients in accordance with the
6
Illinois Medicaid Program in conjunction with the Department
7
of Human Services.
8

All medical providers providing medical assistance to
9
pregnant individuals under this Code shall receive information
10
from the Department on the availability of services under any
11
program providing case management services for addicted
12
individuals, including information on appropriate referrals
13
for other social services that may be needed by addicted
14
individuals in addition to treatment for addiction.
15

The Illinois Department, in cooperation with the
16
Departments of Human Services (as successor to the Department
17
of Alcoholism and Substance Abuse) and Public Health, through
18
a public awareness campaign, may provide information
19
concerning treatment for alcoholism and drug abuse and
20
addiction, prenatal health care, and other pertinent programs
21
directed at reducing the number of drug-affected infants born
22
to recipients of medical assistance.
23

Neither the Department of Healthcare and Family Services
24
nor the Department of Human Services shall sanction the
25
recipient solely on the basis of the recipient's substance
26
abuse.

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The Illinois Department shall establish such regulations
2
governing the dispensing of health services under this Article
3
as it shall deem appropriate. The Department should seek the
4
advice of formal professional advisory committees appointed by
5
the Director of the Illinois Department for the purpose of
6
providing regular advice on policy and administrative matters,
7
information dissemination and educational activities for
8
medical and health care providers, and consistency in
9
procedures to the Illinois Department.
10

The Illinois Department may develop and contract with
11
Partnerships of medical providers to arrange medical services
12
for persons eligible under Section 5-2 of this Code.
13
Implementation of this Section may be by demonstration
14
projects in certain geographic areas. The Partnership shall be
15
represented by a sponsor organization. The Department, by
16
rule, shall develop qualifications for sponsors of
17
Partnerships. Nothing in this Section shall be construed to
18
require that the sponsor organization be a medical
19
organization.
20

The sponsor must negotiate formal written contracts with
21
medical providers for physician services, inpatient and
22
outpatient hospital care, home health services, treatment for
23
alcoholism and substance abuse, and other services determined
24
necessary by the Illinois Department by rule for delivery by
25
Partnerships. Physician services must include prenatal and
26
obstetrical care. The Illinois Department shall reimburse

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medical services delivered by Partnership providers to clients
2
in target areas according to provisions of this Article and
3
the Illinois Health Finance Reform Act, except that:
4

(1) Physicians participating in a Partnership and
5

providing certain services, which shall be determined by
6

the Illinois Department, to persons in areas covered by
7

the Partnership may receive an additional surcharge for
8

such services.
9

(2) The Department may elect to consider and negotiate
10

financial incentives to encourage the development of
11

Partnerships and the efficient delivery of medical care.
12

(3) Persons receiving medical services through
13

Partnerships may receive medical and case management
14

services above the level usually offered through the
15

medical assistance program.
16

Medical providers shall be required to meet certain
17
qualifications to participate in Partnerships to ensure the
18
delivery of high quality medical services. These
19
qualifications shall be determined by rule of the Illinois
20
Department and may be higher than qualifications for
21
participation in the medical assistance program. Partnership
22
sponsors may prescribe reasonable additional qualifications
23
for participation by medical providers, only with the prior
24
written approval of the Illinois Department.
25

Nothing in this Section shall limit the free choice of
26
practitioners, hospitals, and other providers of medical

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services by clients. In order to ensure patient freedom of
2
choice, the Illinois Department shall immediately promulgate
3
all rules and take all other necessary actions so that
4
provided services may be accessed from therapeutically
5
certified optometrists to the full extent of the Illinois
6
Optometric Practice Act of 1987 without discriminating between
7
service providers.
8

The Department shall apply for a waiver from the United
9
States Health Care Financing Administration to allow for the
10
implementation of Partnerships under this Section.
11

The Illinois Department shall require health care
12
providers to maintain records that document the medical care
13
and services provided to recipients of Medical Assistance
14
under this Article. Such records must be retained for a period
15
of not less than 6 years from the date of service or as
16
provided by applicable State law, whichever period is longer,
17
except that if an audit is initiated within the required
18
retention period then the records must be retained until the
19
audit is completed and every exception is resolved. The
20
Illinois Department shall require health care providers to
21
make available, when authorized by the patient, in writing,
22
the medical records in a timely fashion to other health care
23
providers who are treating or serving persons eligible for
24
Medical Assistance under this Article. All dispensers of
25
medical services shall be required to maintain and retain
26
business and professional records sufficient to fully and

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accurately document the nature, scope, details and receipt of
2
the health care provided to persons eligible for medical
3
assistance under this Code, in accordance with regulations
4
promulgated by the Illinois Department. The rules and
5
regulations shall require that proof of the receipt of
6
prescription drugs, dentures, prosthetic devices and
7
eyeglasses by eligible persons under this Section accompany
8
each claim for reimbursement submitted by the dispenser of
9
such medical services. No such claims for reimbursement shall
10
be approved for payment by the Illinois Department without
11
such proof of receipt, unless the Illinois Department shall
12
have put into effect and shall be operating a system of
13
post-payment audit and review which shall, on a sampling
14
basis, be deemed adequate by the Illinois Department to assure
15
that such drugs, dentures, prosthetic devices and eyeglasses
16
for which payment is being made are actually being received by
17
eligible recipients. Within 90 days after September 16, 1984
18
(the effective date of Public Act 83-1439), the Illinois
19
Department shall establish a current list of acquisition costs
20
for all prosthetic devices and any other items recognized as
21
medical equipment and supplies reimbursable under this Article
22
and shall update such list on a quarterly basis, except that
23
the acquisition costs of all prescription drugs shall be
24
updated no less frequently than every 30 days as required by
25
Section 5-5.12.
26

Notwithstanding any other law to the contrary, the

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Illinois Department shall, within 365 days after July 22, 2013
2
(the effective date of Public Act 98-104), establish
3
procedures to permit skilled care facilities licensed under
4
the Nursing Home Care Act to submit monthly billing claims for
5
reimbursement purposes. Following development of these
6
procedures, the Department shall, by July 1, 2016, test the
7
viability of the new system and implement any necessary
8
operational or structural changes to its information
9
technology platforms in order to allow for the direct
10
acceptance and payment of nursing home claims.
11

Notwithstanding any other law to the contrary, the
12
Illinois Department shall, within 365 days after August 15,
13
2014 (the effective date of Public Act 98-963), establish
14
procedures to permit ID/DD facilities licensed under the ID/DD
15
Community Care Act and MC/DD facilities licensed under the
16
MC/DD Act to submit monthly billing claims for reimbursement
17
purposes. Following development of these procedures, the
18
Department shall have an additional 365 days to test the
19
viability of the new system and to ensure that any necessary
20
operational or structural changes to its information
21
technology platforms are implemented.
22

The Illinois Department shall require all dispensers of
23
medical services, other than an individual practitioner or
24
group of practitioners, desiring to participate in the Medical
25
Assistance program established under this Article to disclose
26
all financial, beneficial, ownership, equity, surety or other

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interests in any and all firms, corporations, partnerships,
2
associations, business enterprises, joint ventures, agencies,
3
institutions or other legal entities providing any form of
4
health care services in this State under this Article.
5

The Illinois Department may require that all dispensers of
6
medical services desiring to participate in the medical
7
assistance program established under this Article disclose,
8
under such terms and conditions as the Illinois Department may
9
by rule establish, all inquiries from clients and attorneys
10
regarding medical bills paid by the Illinois Department, which
11
inquiries could indicate potential existence of claims or
12
liens for the Illinois Department.
13

Enrollment of a vendor shall be subject to a provisional
14
period and shall be conditional for one year. During the
15
period of conditional enrollment, the Department may terminate
16
the vendor's eligibility to participate in, or may disenroll
17
the vendor from, the medical assistance program without cause.
18
Unless otherwise specified, such termination of eligibility or
19
disenrollment is not subject to the Department's hearing
20
process. However, a disenrolled vendor may reapply without
21
penalty.
22

The Department has the discretion to limit the conditional
23
enrollment period for vendors based upon the category of risk
24
of the vendor.
25

Prior to enrollment and during the conditional enrollment
26
period in the medical assistance program, all vendors shall be

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subject to enhanced oversight, screening, and review based on
2
the risk of fraud, waste, and abuse that is posed by the
3
category of risk of the vendor. The Illinois Department shall
4
establish the procedures for oversight, screening, and review,
5
which may include, but need not be limited to: criminal and
6
financial background checks; fingerprinting; license,
7
certification, and authorization verifications; unscheduled or
8
unannounced site visits; database checks; prepayment audit
9
reviews; audits; payment caps; payment suspensions; and other
10
screening as required by federal or State law.
11

The Department shall define or specify the following: (i)
12
by provider notice, the "category of risk of the vendor" for
13
each type of vendor, which shall take into account the level of
14
screening applicable to a particular category of vendor under
15
federal law and regulations; (ii) by rule or provider notice,
16
the maximum length of the conditional enrollment period for
17
each category of risk of the vendor; and (iii) by rule, the
18
hearing rights, if any, afforded to a vendor in each category
19
of risk of the vendor that is terminated or disenrolled during
20
the conditional enrollment period.
21

To be eligible for payment consideration, a vendor's
22
payment claim or bill, either as an initial claim or as a
23
resubmitted claim following prior rejection, must be received
24
by the Illinois Department, or its fiscal intermediary, no
25
later than 180 days after the latest date on the claim on which
26
medical goods or services were provided, with the following

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exceptions:
2

(1) In the case of a provider whose enrollment is in
3

process by the Illinois Department, the 180-day period
4

shall not begin until the date on the written notice from
5

the Illinois Department that the provider enrollment is
6

complete.
7

(2) In the case of errors attributable to the Illinois
8

Department or any of its claims processing intermediaries
9

which result in an inability to receive, process, or
10

adjudicate a claim, the 180-day period shall not begin
11

until the provider has been notified of the error.
12

(3) In the case of a provider for whom the Illinois
13

Department initiates the monthly billing process.
14

(4) In the case of a provider operated by a unit of
15

local government with a population exceeding 3,000,000
16

when local government funds finance federal participation
17

for claims payments.
18

For claims for services rendered during a period for which
19
a recipient received retroactive eligibility, claims must be
20
filed within 180 days after the Department determines the
21
applicant is eligible. For claims for which the Illinois
22
Department is not the primary payer, claims must be submitted
23
to the Illinois Department within 180 days after the final
24
adjudication by the primary payer.
25

In the case of long term care facilities, within 120
26
calendar days of receipt by the facility of required

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prescreening information, new admissions with associated
2
admission documents shall be submitted through the Medical
3
Electronic Data Interchange (MEDI) or the Recipient
4
Eligibility Verification (REV) System or shall be submitted
5
directly to the Department of Human Services using required
6
admission forms. Effective September 1, 2014, admission
7
documents, including all prescreening information, must be
8
submitted through MEDI or REV. Confirmation numbers assigned
9
to an accepted transaction shall be retained by a facility to
10
verify timely submittal. Once an admission transaction has
11
been completed, all resubmitted claims following prior
12
rejection are subject to receipt no later than 180 days after
13
the admission transaction has been completed.
14

Claims that are not submitted and received in compliance
15
with the foregoing requirements shall not be eligible for
16
payment under the medical assistance program, and the State
17
shall have no liability for payment of those claims.
18

To the extent consistent with applicable information and
19
privacy, security, and disclosure laws, State and federal
20
agencies and departments shall provide the Illinois Department
21
access to confidential and other information and data
22
necessary to perform eligibility and payment verifications and
23
other Illinois Department functions. This includes, but is not
24
limited to: information pertaining to licensure;
25
certification; earnings; immigration status; citizenship; wage
26
reporting; unearned and earned income; pension income;

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employment; supplemental security income; social security
2
numbers; National Provider Identifier (NPI) numbers; the
3
National Practitioner Data Bank (NPDB); program and agency
4
exclusions; taxpayer identification numbers; tax delinquency;
5
corporate information; and death records.
6

The Illinois Department shall enter into agreements with
7
State agencies and departments, and is authorized to enter
8
into agreements with federal agencies and departments, under
9
which such agencies and departments shall share data necessary
10
for medical assistance program integrity functions and
11
oversight. The Illinois Department shall develop, in
12
cooperation with other State departments and agencies, and in
13
compliance with applicable federal laws and regulations,
14
appropriate and effective methods to share such data. At a
15
minimum, and to the extent necessary to provide data sharing,
16
the Illinois Department shall enter into agreements with State
17
agencies and departments, and is authorized to enter into
18
agreements with federal agencies and departments, including,
19
but not limited to: the Secretary of State; the Department of
20
Revenue; the Department of Public Health; the Department of
21
Human Services; and the Department of Financial and
22
Professional Regulation.
23

Beginning in fiscal year 2013, the Illinois Department
24
shall set forth a request for information to identify the
25
benefits of a pre-payment, post-adjudication, and post-edit
26
claims system with the goals of streamlining claims processing

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and provider reimbursement, reducing the number of pending or
2
rejected claims, and helping to ensure a more transparent
3
adjudication process through the utilization of: (i) provider
4
data verification and provider screening technology; and (ii)
5
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
6
post-adjudicated predictive modeling with an integrated case
7
management system with link analysis. Such a request for
8
information shall not be considered as a request for proposal
9
or as an obligation on the part of the Illinois Department to
10
take any action or acquire any products or services.
11

The Illinois Department shall establish policies,
12
procedures, standards and criteria by rule for the
13
acquisition, repair and replacement of orthotic and prosthetic
14
devices and durable medical equipment. Such rules shall
15
provide, but not be limited to, the following services: (1)
16
immediate repair or replacement of such devices by recipients;
17
and (2) rental, lease, purchase or lease-purchase of durable
18
medical equipment in a cost-effective manner, taking into
19
consideration the recipient's medical prognosis, the extent of
20
the recipient's needs, and the requirements and costs for
21
maintaining such equipment. Subject to prior approval, such
22
rules shall enable a recipient to temporarily acquire and use
23
alternative or substitute devices or equipment pending repairs
24
or replacements of any device or equipment previously
25
authorized for such recipient by the Department.
26
Notwithstanding any provision of Section 5-5f to the contrary,

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the Department may, by rule, exempt certain replacement
2
wheelchair parts from prior approval and, for wheelchairs,
3
wheelchair parts, wheelchair accessories, and related seating
4
and positioning items, determine the wholesale price by
5
methods other than actual acquisition costs.
6

The Department shall require, by rule, all providers of
7
durable medical equipment to be accredited by an accreditation
8
organization approved by the federal Centers for Medicare and
9
Medicaid Services and recognized by the Department in order to
10
bill the Department for providing durable medical equipment to
11
recipients. No later than 15 months after the effective date
12
of the rule adopted pursuant to this paragraph, all providers
13
must meet the accreditation requirement.
14

In order to promote environmental responsibility, meet the
15
needs of recipients and enrollees, and achieve significant
16
cost savings, the Department, or a managed care organization
17
under contract with the Department, may provide recipients or
18
managed care enrollees who have a prescription or Certificate
19
of Medical Necessity access to refurbished durable medical
20
equipment under this Section (excluding prosthetic and
21
orthotic devices as defined in the Orthotics, Prosthetics, and
22
Pedorthics Practice Act and complex rehabilitation technology
23
products and associated services) through the State's
24
assistive technology program's reutilization program, using
25
staff with the Assistive Technology Professional (ATP)
26
Certification if the refurbished durable medical equipment:

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(i) is available; (ii) is less expensive, including shipping
2
costs, than new durable medical equipment of the same type;
3
(iii) is able to withstand at least 3 years of use; (iv) is
4
cleaned, disinfected, sterilized, and safe in accordance with
5
federal Food and Drug Administration regulations and guidance
6
governing the reprocessing of medical devices in health care
7
settings; and (v) equally meets the needs of the recipient or
8
enrollee. The reutilization program shall confirm that the
9
recipient or enrollee is not already in receipt of the same or
10
similar equipment from another service provider, and that the
11
refurbished durable medical equipment equally meets the needs
12
of the recipient or enrollee. Nothing in this paragraph shall
13
be construed to limit recipient or enrollee choice to obtain
14
new durable medical equipment or place any additional prior
15
authorization conditions on enrollees of managed care
16
organizations.
17

The Department shall execute, relative to the nursing home
18
prescreening project, written inter-agency agreements with the
19
Department of Human Services and the Department on Aging, to
20
effect the following: (i) intake procedures and common
21
eligibility criteria for those persons who are receiving
22
non-institutional services; and (ii) the establishment and
23
development of non-institutional services in areas of the
24
State where they are not currently available or are
25
undeveloped; and (iii) notwithstanding any other provision of
26
law, subject to federal approval, on and after July 1, 2012, an

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increase in the determination of need (DON) scores from 29 to
2
37 for applicants for institutional and home and
3
community-based long term care; if and only if federal
4
approval is not granted, the Department may, in conjunction
5
with other affected agencies, implement utilization controls
6
or changes in benefit packages to effectuate a similar savings
7
amount for this population; and (iv) no later than July 1,
8
2013, minimum level of care eligibility criteria for
9
institutional and home and community-based long term care; and
10
(v) no later than October 1, 2013, establish procedures to
11
permit long term care providers access to eligibility scores
12
for individuals with an admission date who are seeking or
13
receiving services from the long term care provider. In order
14
to select the minimum level of care eligibility criteria, the
15
Governor shall establish a workgroup that includes affected
16
agency representatives and stakeholders representing the
17
institutional and home and community-based long term care
18
interests. This Section shall not restrict the Department from
19
implementing lower level of care eligibility criteria for
20
community-based services in circumstances where federal
21
approval has been granted.
22

The Illinois Department shall develop and operate, in
23
cooperation with other State Departments and agencies and in
24
compliance with applicable federal laws and regulations,
25
appropriate and effective systems of health care evaluation
26
and programs for monitoring of utilization of health care

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services and facilities, as it affects persons eligible for
2
medical assistance under this Code.
3

The Illinois Department shall report annually to the
4
General Assembly, no later than the second Friday in April of
5
1979 and each year thereafter, in regard to:
6

(a) actual statistics and trends in utilization of
7

medical services by public aid recipients;
8

(b) actual statistics and trends in the provision of
9

the various medical services by medical vendors;
10

(c) current rate structures and proposed changes in
11

those rate structures for the various medical vendors; and
12

(d) efforts at utilization review and control by the
13

Illinois Department.
14

The period covered by each report shall be the 3 years
15
ending on the June 30 prior to the report. The report shall
16
include suggested legislation for consideration by the General
17
Assembly. The requirement for reporting to the General
18
Assembly shall be satisfied by filing copies of the report as
19
required by Section 3.1 of the General Assembly Organization
20
Act, and filing such additional copies with the State
21
Government Report Distribution Center for the General Assembly
22
as is required under paragraph (t) of Section 7 of the State
23
Library Act.
24

Rulemaking authority to implement Public Act 95-1045, if
25
any, is conditioned on the rules being adopted in accordance
26
with all provisions of the Illinois Administrative Procedure

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Act and all rules and procedures of the Joint Committee on
2
Administrative Rules; any purported rule not so adopted, for
3
whatever reason, is unauthorized.
4

On and after July 1, 2012, the Department shall reduce any
5
rate of reimbursement for services or other payments or alter
6
any methodologies authorized by this Code to reduce any rate
7
of reimbursement for services or other payments in accordance
8
with Section 5-5e.
9

Because kidney transplantation can be an appropriate,
10
cost-effective alternative to renal dialysis when medically
11
necessary and notwithstanding the provisions of Section 1-11
12
of this Code, beginning October 1, 2014, the Department shall
13
cover kidney transplantation for noncitizens with end-stage
14
renal disease who are not eligible for comprehensive medical
15
benefits, who meet the residency requirements of Section 5-3
16
of this Code, and who would otherwise meet the financial
17
requirements of the appropriate class of eligible persons
18
under Section 5-2 of this Code. To qualify for coverage of
19
kidney transplantation, such person must be receiving
20
emergency renal dialysis services covered by the Department.
21
Providers under this Section shall be prior approved and
22
certified by the Department to perform kidney transplantation
23
and the services under this Section shall be limited to
24
services associated with kidney transplantation.
25

Notwithstanding any other provision of this Code to the
26
contrary, on or after July 1, 2015, all
FDA-approved

FDA

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1
approved
forms of medication assisted treatment prescribed for
2
the treatment of alcohol dependence or treatment of opioid
3
dependence shall be covered under both fee-for-service and
4
managed care medical assistance programs for persons who are
5
otherwise eligible for medical assistance under this Article
6
and shall not be subject to any (1) utilization control, other
7
than those established under the American Society of Addiction
8
Medicine patient placement criteria, (2) prior authorization
9
mandate, (3) lifetime restriction limit mandate, or (4)
10
limitations on dosage.
11

On or after July 1, 2015, opioid antagonists prescribed
12
for the treatment of an opioid overdose, including the
13
medication product, administration devices, and any pharmacy
14
fees or hospital fees related to the dispensing, distribution,
15
and administration of the opioid antagonist, shall be covered
16
under the medical assistance program for persons who are
17
otherwise eligible for medical assistance under this Article.
18
As used in this Section, "opioid antagonist" means a drug that
19
binds to opioid receptors and blocks or inhibits the effect of
20
opioids acting on those receptors, including, but not limited
21
to, naloxone hydrochloride or any other similarly acting drug
22
approved by the U.S. Food and Drug Administration. The
23
Department shall not impose a copayment on the coverage
24
provided for naloxone hydrochloride under the medical
25
assistance program.
26

Upon federal approval, the Department shall provide

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coverage and reimbursement for all drugs that are approved for
2
marketing by the federal Food and Drug Administration and that
3
are recommended by the federal Public Health Service or the
4
United States Centers for Disease Control and Prevention for
5
pre-exposure prophylaxis and related pre-exposure prophylaxis
6
services, including, but not limited to, HIV and sexually
7
transmitted infection screening, treatment for sexually
8
transmitted infections, medical monitoring, assorted labs, and
9
counseling to reduce the likelihood of HIV infection among
10
individuals who are not infected with HIV but who are at high
11
risk of HIV infection.
12

A federally qualified health center, as defined in Section
13
1905(l)(2)(B) of the federal Social Security Act, shall be
14
reimbursed by the Department in accordance with the federally
15
qualified health center's encounter rate for services provided
16
to medical assistance recipients that are performed by a
17
dental hygienist, as defined under the Illinois Dental
18
Practice Act, working under the general supervision of a
19
dentist and employed by a federally qualified health center.
20

Within 90 days after October 8, 2021 (the effective date
21
of Public Act 102-665), the Department shall seek federal
22
approval of a State Plan amendment to expand coverage for
23
family planning services that includes presumptive eligibility
24
to individuals whose income is at or below 208% of the federal
25
poverty level. Coverage under this Section shall be effective
26
beginning no later than December 1, 2022.

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Subject to approval by the federal Centers for Medicare
2
and Medicaid Services of a Title XIX State Plan amendment
3
electing the Program of All-Inclusive Care for the Elderly
4
(PACE) as a State Medicaid option, as provided for by Subtitle
5
I (commencing with Section 4801) of Title IV of the Balanced
6
Budget Act of 1997 (Public Law 105-33) and Part 460
7
(commencing with Section 460.2) of Subchapter E of Title 42 of
8
the Code of Federal Regulations, PACE program services shall
9
become a covered benefit of the medical assistance program,
10
subject to criteria established in accordance with all
11
applicable laws.
12

Notwithstanding any other provision of this Code,
13
community-based pediatric palliative care from a trained
14
interdisciplinary team shall be covered under the medical
15
assistance program as provided in Section 15 of the Pediatric
16
Palliative Care Act.
17

Notwithstanding any other provision of this Code, within
18
12 months after June 2, 2022 (the effective date of Public Act
19
102-1037) and subject to federal approval, acupuncture
20
services performed by an acupuncturist licensed under the
21
Acupuncture Practice Act who is acting within the scope of his
22
or her license shall be covered under the medical assistance
23
program. The Department shall apply for any federal waiver or
24
State Plan amendment, if required, to implement this
25
paragraph. The Department may adopt any rules, including
26
standards and criteria, necessary to implement this paragraph.

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1

Notwithstanding any other provision of this Code, the
2
medical assistance program shall, subject to federal approval,
3
reimburse hospitals for costs associated with a newborn
4
screening test for the presence of metachromatic
5
leukodystrophy, as required under the Newborn
Metabolic

6
Screening Act, at a rate not less than the fee charged by the
7
Department of Public Health. Notwithstanding any other
8
provision of this Code, the medical assistance program shall,
9
subject to appropriation and federal approval, also reimburse
10
hospitals for costs associated with all newborn screening
11
tests added on and after
August 9, 2024 (
the effective date of
12
Public Act 103-909)

this amendatory Act of the 103rd General
13
Assembly
to the Newborn
Metabolic
Screening Act and required
14
to be performed under that Act at a rate not less than the fee
15
charged by the Department of Public Health. The Department
16
shall seek federal approval before the implementation of the
17
newborn screening test fees by the Department of Public
18
Health.
19

Notwithstanding any other provision of this Code,
20
beginning on January 1, 2024, subject to federal approval,
21
cognitive assessment and care planning services provided to a
22
person who experiences signs or symptoms of cognitive
23
impairment, as defined by the Diagnostic and Statistical
24
Manual of Mental Disorders, Fifth Edition, shall be covered
25
under the medical assistance program for persons who are
26
otherwise eligible for medical assistance under this Article.

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Notwithstanding any other provision of this Code,
2
medically necessary reconstructive services that are intended
3
to restore physical appearance shall be covered under the
4
medical assistance program for persons who are otherwise
5
eligible for medical assistance under this Article. As used in
6
this paragraph, "reconstructive services" means treatments
7
performed on structures of the body damaged by trauma to
8
restore physical appearance.
9
(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
10
102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
11
55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
12
eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
13
102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
14
5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
15
102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
16
1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
17
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
18
1-1-24; 103-593, Article 5, Section 5-5, eff. 6-7-24; 103-593,
19
Article 90, Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24;
20
103-808, eff. 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff.
21
8-9-24; revised 10-10-24.)

22

Section 20.
The Newborn Metabolic Screening Act is amended
23
by changing the title of the Act and Sections 0.01 and 2 as
24
follows:

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(410 ILCS 240/Act title)
2

An Act concerning
health

the disease of phenylketonuria
3
and other metabolic diseases, designating certain powers and
4
duties in relation thereto, providing penalties for violation
5
thereof, to repeal an Act therein named and to make an
6
appropriation in connection therewith
.

7

(410 ILCS 240/0.01)

(from Ch. 111 1/2, par. 4902.9)
8

Sec. 0.01.
Short title.
This Act may be cited as the
9
Newborn
Metabolic
Screening Act.
10
(Source: P.A. 95-695, eff. 11-5-07.)

11

(410 ILCS 240/2)

(from Ch. 111 1/2, par. 4904)
12

Sec. 2.
General provisions.
The Department of Public
13
Health shall administer the provisions of this Act and shall:
14

(a) Institute and carry on an intensive educational
15
program among physicians, hospitals, public health nurses and
16
the public concerning disorders included in newborn screening.
17
This educational program shall include information about the
18
nature of the diseases and examinations for the detection of
19
the diseases in early infancy in order that measures may be
20
taken to prevent the disabilities resulting from the diseases.
21

(a-5) Require that all newborns be screened for the
22
presence of certain genetic, metabolic, and congenital
23
anomalies
, including hearing disorders,
as determined by the
24
Department, by rule.

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(a-5.1) Require that all blood and biological specimens
2
collected pursuant to this Act or the rules adopted under this
3
Act be submitted for testing to the nearest Department
4
laboratory designated to perform such tests. The following
5
provisions shall apply concerning testing:
6

(1) Beginning July 1, 2015, the base fee for newborn
7

screening services shall be $118.
Beginning July 1, 2026,
8

the base fee for newborn screening services shall be $165.
9

The amount of 22% of the base fee must be allocated to the
10

Department for the Early Hearing Detection and
11

Intervention Program.
The Department may develop a
12

reasonable fee structure and may levy additional fees
13

according to such structure to cover the cost of providing
14

these

this
testing
services

service
and for the follow-up
15

of infants with an abnormal screening test; however,
16

additional fees may be levied no sooner than 6 months
17

prior to the beginning of testing for a new genetic,
18

metabolic, or congenital disorder. Fees collected from the
19

provision of this testing service shall be placed in the
20

Metabolic Screening and Treatment Fund. Other State and
21

federal funds for expenses related to metabolic
, hearing,
22

or congenital disorder
screening, follow-up, and treatment
23

programs may also be placed in the Fund.
24

(2) Moneys shall be appropriated from the Fund to the
25

Department solely for the purposes of providing newborn
26

screening, follow-up, and treatment programs. Nothing in

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this Act shall be construed to prohibit any licensed
2

medical facility from collecting additional specimens for
3

testing for metabolic or neonatal diseases or any other
4

diseases or conditions, as it deems fit. Any person
5

violating the provisions of this subsection (a-5.1) is
6

guilty of a petty offense.
7

(3) If the Department is unable to provide the
8

screening using the State Laboratory, it shall temporarily
9

provide such screening through an accredited laboratory
10

selected by the Department until the Department has the
11

capacity to provide screening through the State
12

Laboratory. If screening is provided on a temporary basis
13

through an accredited laboratory, the Department shall
14

substitute the fee charged by the accredited laboratory,
15

plus a 5% surcharge for documentation and handling, for
16

the fee authorized in this subsection (a-5.1).
This
17

paragraph (3) does not apply to hearing screenings.

18

(a-5.2) Maintain a registry of cases, including
19
information of importance for the purpose of follow-up
20
services to assess long-term outcomes.
21

(a-5.3) Supply the necessary metabolic treatment formulas
22
where practicable for diagnosed cases of amino acid metabolism
23
disorders, including phenylketonuria, organic acid disorders,
24
and fatty acid oxidation disorders for as long as medically
25
indicated, when the product is not available through other
26
State agencies.

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(a-5.4) Arrange for or provide public health nursing,
2
nutrition, and social services and clinical consultation as
3
indicated.
4

(a-5.5) Utilize the Genetic and Metabolic Diseases
5
Advisory Committee established under the Genetic and Metabolic
6
Diseases Advisory Committee Act to provide guidance and
7
recommendations to the Department's newborn screening program.
8
The Genetic and Metabolic Diseases Advisory Committee shall
9
review the feasibility and advisability of including
10
additional metabolic, genetic, and congenital disorders in the
11
newborn screening panel, according to a review protocol
12
applied to each suggested addition to the screening panel. The
13
Department shall consider the recommendations of the Genetic
14
and Metabolic Diseases Advisory Committee in determining
15
whether to include an additional disorder in the screening
16
panel prior to proposing an administrative rule concerning
17
inclusion of an additional disorder in the newborn screening
18
panel.
This subsection (a-5.5) does not apply to hearing
19
screenings.
Notwithstanding any other provision of law, no new
20
screening may begin prior to the occurrence of all the
21
following:
22

(1) the establishment and verification of relevant and
23

appropriate performance specifications as defined under
24

the federal Clinical Laboratory Improvement Amendments and
25

regulations thereunder for U.S. Food and Drug
26

Administration-cleared or in-house developed methods,

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performed under an institutional review board-approved
2

protocol, if required;
3

(2) the availability of quality assurance testing
4

methodology for the processes set forth in item (1) of
5

this subsection (a-5.5);
6

(3) the acquisition and installment by the Department
7

of the equipment necessary to implement the screening
8

tests;
9

(4) the establishment of precise threshold values
10

ensuring defined disorder identification for each
11

screening test;
12

(5) the authentication of pilot testing achieving each
13

milestone described in items (1) through (4) of this
14

subsection (a-5.5) for each disorder screening test; and
15

(6) the authentication of achieving the potential of
16

high throughput standards for statewide volume of each
17

disorder screening test concomitant with each milestone
18

described in items (1) through (4) of this subsection
19

(a-5.5).
20

(a-6) (Blank).
21

(a-7) (Blank).
22

(a-8) (Blank).
23

(b) (Blank).
24

(c) (Blank).
25

(d) (Blank).
26

(e) (Blank).

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1
(Source: P.A. 98-440, eff. 8-16-13; 98-756, eff. 7-16-14;
2
99-403, eff. 8-19-15.)

3

Section 25.
The Genetic Information Privacy Act is amended
4
by changing Section 30 as follows:

5

(410 ILCS 513/30)
6

Sec. 30.
Disclosure of person tested and test results.
7

(a) No person may disclose or be compelled to disclose the
8
identity of any person upon whom a genetic test is performed or
9
the results of a genetic test in a manner that permits
10
identification of the subject of the test, except to the
11
following persons:
12

(1) The subject of the test or the subject's legally
13

authorized representative. This paragraph does not create
14

a duty or obligation under which a health care provider
15

must notify the subject's spouse or legal guardian of the
16

test results, and no such duty or obligation shall be
17

implied. No civil liability or criminal sanction under
18

this Act shall be imposed for any disclosure or
19

nondisclosure of a test result to a spouse by a physician
20

acting in good faith under this paragraph. For the purpose
21

of any proceedings, civil or criminal, the good faith of
22

any physician acting under this paragraph shall be
23

presumed.
24

(2) Any person designated in a specific written

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legally effective authorization for release of the test
2

results executed by the subject of the test or the
3

subject's legally authorized representative.
4

(3) An authorized agent or employee of a health
5

facility or health care provider if the health facility or
6

health care provider itself is authorized to obtain the
7

test results, the agent or employee provides patient care,
8

and the agent or employee has a need to know the
9

information in order to conduct the tests or provide care
10

or treatment.
11

(4) A health facility, health care provider, or health
12

care professional that procures, processes, distributes,
13

or uses:
14

(A) a human body part from a deceased person with
15

respect to medical information regarding that person;
16

or
17

(B) semen provided prior to the effective date of
18

this Act for the purpose of artificial insemination.
19

(5) Health facility staff committees for the purposes
20

of conducting program monitoring, program evaluation, or
21

service reviews.
22

(6) In the case of a minor under 18 years of age, the
23

health care provider, health care professional, or health
24

facility who ordered the test shall make a reasonable
25

effort to notify the minor's parent or legal guardian if,
26

in the professional judgment of the health care provider,

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health care professional, or health facility, notification
2

would be in the best interest of the minor and the health
3

care provider, health care professional, or health
4

facility has first sought unsuccessfully to persuade the
5

minor to notify the parent or legal guardian or after a
6

reasonable time after the minor has agreed to notify the
7

parent or legal guardian, the health care provider, health
8

care professional, or health facility has reason to
9

believe that the minor has not made the notification. This
10

paragraph shall not create a duty or obligation under
11

which a health care provider, health care professional, or
12

health facility must notify the minor's parent or legal
13

guardian of the test results, nor shall a duty or
14

obligation be implied. No civil liability or criminal
15

sanction under this Act shall be imposed for any
16

notification or non-notification of a minor's test result
17

by a health care provider, health care professional, or
18

health facility acting in good faith under this paragraph.
19

For the purpose of any proceeding, civil or criminal, the
20

good faith of any health care provider, health care
21

professional, or health facility acting under this
22

paragraph shall be presumed.

23

(b) All information and records held by a State agency,
24
local health authority, or health oversight agency pertaining
25
to genetic information shall be strictly confidential and
26
exempt from copying and inspection under the Freedom of

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1
Information Act. The information and records shall not be
2
released or made public by the State agency, local health
3
authority, or health oversight agency and shall not be
4
admissible as evidence nor discoverable in any action of any
5
kind in any court or before any tribunal, board, agency, or
6
person and shall be treated in the same manner as the
7
information and those records subject to the provisions of
8
Part 21 of Article VIII of the Code of Civil Procedure except
9
under the following circumstances:
10

(A) when made with the written consent of all
11

persons to whom the information pertains;
12

(B) when authorized by Section 5-4-3 of the
13

Unified Code of Corrections;
14

(C) when made for the sole purpose of implementing
15

the Newborn
Metabolic
Screening Act and rules; or
16

(D) when made under the authorization of the
17

Illinois Parentage Act of 2015.
18

Disclosure shall be limited to those who have a need to
19
know the information, and no additional disclosures may be
20
made.
21

(c) Disclosure by an insurer in accordance with the
22
requirements of the Article XL of the Illinois Insurance Code
23
shall be deemed compliance with this Section.
24
(Source: P.A. 98-1046, eff. 1-1-15; 99-85, eff. 1-1-16
.)

25

Section 95.
No acceleration or delay.
Where this Act makes

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changes in a statute that is represented in this Act by text
2
that is not yet or no longer in effect (for example, a Section
3
represented by multiple versions), the use of that text does
4
not accelerate or delay the taking effect of (i) the changes
5
made by this Act or (ii) provisions derived from any other
6
Public Act.

7

Section 99.
Effective date.
This Act takes effect upon
8
becoming law.

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